Acute alcoholic hepatitis: Difference between revisions
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==Clinical Features== | ==Clinical Features== | ||
===Symptoms=== | ===Symptoms=== | ||
*abdominal pain | *[[abdominal pain]] | ||
*N/V | *[[N/V]] | ||
*weight loss / fatigue / anorexia | *weight loss / fatigue / anorexia | ||
===Signs=== | ===Signs=== | ||
*RUQ tenderness | *[[RUQ tenderness]] | ||
*jaundice | *[[jaundice]] | ||
*fever | *[[fever]] | ||
*hepatomegaly | *[[hepatomegaly]] | ||
*ascites | *[[ascites]] | ||
*encephalopathy | *[[encephalopathy]] | ||
*spider angioma | *spider angioma | ||
*GI bleed/varices | *[[GI bleed]]/varices | ||
*malnutrition | *malnutrition | ||
*symptoms of alcohol withdrawal | *symptoms of [[alcohol withdrawal]] | ||
Cirrhosis is found in 50-60% of cases of alcoholic hepatitis ( | Cirrhosis is found in 50-60% of cases of alcoholic hepatitis<ref>Basra, Gurjot,et. al. "Symptoms and Signs of Acute Alcoholic Hepatitis." World J Hepatol. 2011 May 27; 3(5): 118–120.</ref> | ||
==Differential Diagnosis== | ==Differential Diagnosis== | ||
*alcoholic [[pancreatitis]] | *alcoholic [[pancreatitis]] | ||
*[[gallstones]] | *[[gallstones]] | ||
*Budd-Chiari syndrome | *[[Budd-Chiari syndrome]] | ||
{{Acute hepatitis causes}} | {{Acute hepatitis causes}} | ||
==Diagnosis== | ==Diagnosis== | ||
===Work Up=== | |||
====Labs==== | |||
==Work Up== | |||
===Labs=== | |||
*CBC | *CBC | ||
**Leukocytosis with elevated ANC | **Leukocytosis with elevated ANC | ||
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*LFTs | *LFTs | ||
**Elevated AST/ALT (characteristically >2:1 and < 500 IU/L) | **Elevated AST/ALT (characteristically >2:1 and < 500 IU/L) | ||
**GGT alone is less reliable (low sensitivity and specificity ( | **GGT alone is less reliable (low sensitivity and specificity)<ref>O'Shea RS, Dasarathy S, McCullough AJ (2010) Alcoholic liver disease. Hepatology 51: 307–328. doi: 10.1002/hep.23258</ref> | ||
*Coagulation factors | *Coagulation factors | ||
**Elevated PT/INR | **Elevated PT/INR | ||
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*Consider hepatitis panel | *Consider hepatitis panel | ||
===Imaging=== | ====Imaging==== | ||
Consider transabdominal ultrasound if concern for: | Consider transabdominal ultrasound if concern for: | ||
*Biliary obstruction | *Biliary obstruction | ||
*Budd-Chiari syndrome | *Budd-Chiari syndrome | ||
*Hepatic or biliary neoplasms | *Hepatic or biliary neoplasms | ||
===Evaluation=== | |||
Diagnosis is difficult and relies on a good history<ref>O'Shea RS, Dasarathy S, McCullough AJ (2010) Alcoholic liver disease. Hepatology 51: 307–328. doi: 10.1002/hep.23258</ref> | |||
*History of significant alcohol intake | |||
*Clinical evidence of liver disease | |||
*Supporting laboratory abnormalities | |||
**May be nondiagnostic in patients with mild disease or early cirrhosis | |||
==Management== | ==Management== | ||
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High risk, severe cases | High risk, severe cases | ||
*Steroids | *[[Steroids]] | ||
*Pentoxifylline | *Pentoxifylline | ||
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*Maddrey Discriminant Function score ([http://www.mdcalc.com/maddreys-discriminant-function-for-alcoholic-hepatitis/ MDF]) | *Maddrey Discriminant Function score ([http://www.mdcalc.com/maddreys-discriminant-function-for-alcoholic-hepatitis/ MDF]) | ||
*Model for End-Stage Liver Disease score ([http://www.mdcalc.com/meld-score-model-for-end-stage-liver-disease-12-and-older/ MELD]) | *Model for End-Stage Liver Disease score ([http://www.mdcalc.com/meld-score-model-for-end-stage-liver-disease-12-and-older/ MELD]) | ||
*High risk: MDF ≥ 32, MELD ≥ 18, or presence of hepatic encephalopathy ( | *High risk: MDF ≥ 32, MELD ≥ 18, or presence of hepatic encephalopathy<ref>O'Shea RS, Dasarathy S, McCullough AJ (2010) Alcoholic liver disease. Hepatology 51: 307–328. doi: 10.1002/hep.23258</ref> | ||
==Disposition== | ==Disposition== | ||
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**Mild disease/low risk | **Mild disease/low risk | ||
**Nutritional assessment and intervention | **Nutritional assessment and intervention | ||
**Discuss alcohol use and recommend strict abstinence | **Discuss [[alcohol]] use and recommend strict abstinence | ||
*Admit | *Admit | ||
**High risk defined as MDF ≥ 32, MELD ≥ 18, or presence of hepatic encephalopathy | **High risk defined as MDF ≥ 32, MELD ≥ 18, or presence of [[hepatic encephalopathy]] | ||
==See Also== | ==See Also== | ||
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==References== | ==References== | ||
# Privette TW Jr, Carlisle MC, Palma JK. Emergencies of the liver, gallbladder, and pancreas. Emerg Med Clin North Am. 2011 May;29(2):293-317, viii-ix. doi: 10.1016/j.emc.2011.01.008. | # Privette TW Jr, Carlisle MC, Palma JK. Emergencies of the liver, gallbladder, and pancreas. Emerg Med Clin North Am. 2011 May;29(2):293-317, viii-ix. doi: 10.1016/j.emc.2011.01.008. | ||
# 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 | # 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 | ||
<references/> | <references/> | ||
Revision as of 08:06, 20 January 2016
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)
- 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[1]
Differential Diagnosis
- alcoholic pancreatitis
- gallstones
- Budd-Chiari syndrome
Causes of acute hepatitis
- Acetaminophen toxicity (most common cause of acute liver failure in the US[2])
- Viral hepatitis
- Toxoplasmosis
- Acute alcoholic hepatitis
- Toxins
- Ischemic hepatitis
- Autoimmune hepatitis
- Wilson's disease
Diagnosis
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)[3]
- 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
Evaluation
Diagnosis is difficult and relies on a good history[4]
- History of significant alcohol intake
- Clinical evidence of liver disease
- Supporting laboratory abnormalities
- May be nondiagnostic in patients with mild disease or early cirrhosis
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[5]
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
See Also
External Links
References
- Privette TW Jr, Carlisle MC, Palma JK. Emergencies of the liver, gallbladder, and pancreas. Emerg Med Clin North Am. 2011 May;29(2):293-317, viii-ix. doi: 10.1016/j.emc.2011.01.008.
- 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
- ↑ Basra, Gurjot,et. al. "Symptoms and Signs of Acute Alcoholic Hepatitis." World J Hepatol. 2011 May 27; 3(5): 118–120.
- ↑ Ostapowicz G, Fontana RJ, Schiodt FV, et al. Results of a prospective study of acute liver failure at 17 tertiary care centers in the United States. Ann Intern Med. 2002 Dec 17; 137(12): 947-54.
- ↑ O'Shea RS, Dasarathy S, McCullough AJ (2010) Alcoholic liver disease. Hepatology 51: 307–328. doi: 10.1002/hep.23258
- ↑ O'Shea RS, Dasarathy S, McCullough AJ (2010) Alcoholic liver disease. Hepatology 51: 307–328. doi: 10.1002/hep.23258
- ↑ O'Shea RS, Dasarathy S, McCullough AJ (2010) Alcoholic liver disease. Hepatology 51: 307–328. doi: 10.1002/hep.23258