Acute alcoholic hepatitis

Background

Acute alcoholic hepatitis is inflammatory liver disease secondary to alcohol use.

• spectrum from hepatic steatosis to alcoholic hepatitis to cirrhosis
• history of (usually chronic) alcohol abuse (~80 grams of ethanol daily for 5 years (2))
• ranges from subclinical cases to severe multisystem dysfunction

Clinical Features

Symptoms

• abdominal pain
• N/V
• weight loss / fatigue / anorexia

Signs

• RUQ tenderness
• jaundice
• fever
• hepatomegaly
• ascites
• encephalopathy
• spider angioma
• GI bleed/varices
• malnutrition
• symptoms of alcohol withdrawal

Cirrhosis is found in 50-60% of cases of alcoholic hepatitis (2).

Differential Diagnosis

• viral hepatitis
• acetaminophen toxicity
• alcoholic pancreatitis
• gallstones
• Budd-Chiari syndrome

Diagnosis

Diagnosis is difficult and relies on a good history (1).

1. History of significant alcohol intake
2. Clinical evidence of liver disease
3. Supporting laboratory abnormalities

• May be nondiagnostic in patients with mild disease or early cirrhosis

Work Up

Labs

• CBC
  • Leukocytosis with elevated ANC
• Chemistry including magnesium and phosphate
• LFTs
  • Elevated AST/ALT (characteristically >2:1 and < 500 IU/L)
  • GGT alone is less reliable (low sensitivity and specificity)
• Coagulation factors
  • Elevated PT/INR
• Lipase if suspect pancreatitis
• Consider hepatitis panel

Imaging

Consider transabdominal ultrasound if concern for:

• Biliary obstruction
• Budd-Chiari syndrome
• Hepatic or biliary neoplasms

Management

• Control of withdrawal symptoms
• Nutritional support for malnutrition: especially thiamine, folate, pyridoxine, magnesium, phosphate, glucose, and protein

High risk, severe cases

• Steroids
• Pentoxifylline

Prognosis

• Maddrey Discriminant Function score (MDF)
• Model for End-Stage Liver Disease score (MELD)
• High risk: MDF ≥ 32, MELD ≥ 18, or presence of hepatic encephalopathy

Disposition

• Discharge
  • Mild disease/low risk
  • Nutritional assessment and intervention
  • Discuss alcohol use and recommend strict abstinence
• Admit
  • High risk defined as MDF ≥ 32, MELD ≥ 18, or presence of hepatic encephalopathy

References

1. Amini, Maziyar; Runyon, Bruce. "Alcoholic Hepatitis 2010: A clinician's Guide to Diagnosis and Therapy." World of Gatstroenterol 2010 October 21; 16(39):4905-4912
2. Basra, Gurjot,et. al. "Symptoms and Signs of Acute Alcoholic Hepatitis." World J Hepatol. 2011 May 27; 3(5): 118–120.