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)
  • Ranges from subclinical cases to severe multisystem dysfunction

Clinical Features

Symptoms

Signs

Cirrhosis is found in 50-60% of cases of alcoholic hepatitis[1]

Differential Diagnosis

Acute hepatitis

Evaluation

Work Up

Labs

  • CBC
    • Leukocytosis with elevated ANC
  • Chemistry including magnesium and phosphate
  • LFTs - very high elevations possibly more suggestive of viral or drug-induced hepatitis
    • Elevated AST/ALT (characteristically >2:1 and < 500 IU/L)
    • GGT alone is less reliable (low sensitivity and specificity)[2]
  • 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[3]

  • 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

Disposition

  • Discharge
    • Mild disease/low risk
    • Nutritional assessment and intervention
    • Discuss alcohol use and recommend strict abstinence
  • Admit

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]

See Also

External Links

References

  1. Basra, Gurjot,et. al. "Symptoms and Signs of Acute Alcoholic Hepatitis." World J Hepatol. 2011 May 27; 3(5): 118–120.
  2. O'Shea RS, Dasarathy S, McCullough AJ (2010) Alcoholic liver disease. Hepatology 51: 307–328. doi: 10.1002/hep.23258
  3. O'Shea RS, Dasarathy S, McCullough AJ (2010) Alcoholic liver disease. Hepatology 51: 307–328. doi: 10.1002/hep.23258
  4. Mathurin P, Louvet A, Duhamel A, et al. Prednisolone with vs without pentoxifylline and survival of patients with severe alcoholic hepatitis: a randomized clinical trial. JAMA. 2013;310(10):1033-41.
  5. O'Shea RS, Dasarathy S, McCullough AJ (2010) Alcoholic liver disease. Hepatology 51: 307–328. doi: 10.1002/hep.23258