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Alcoholic Hepatitis - by Keon Combie

posted Jun 15, 2015, 2:29 PM by Kevin Hauck

Alcoholic hepatitis

Clinical presentation

- Rapid onset jaundice

- Enlarged and tender liver

- Fever

- Ascites

- Proximal muscle loss

- Can have encephalopathy in severe cases

 

Lab findings

AST: ALT ratio >2. However, this is neither sensitive nor specific

LFTs are rarely higher than 300

Elevated bilis

Elevated INR

Elevated WBCs- neutrophil predominant

 

Differential Diagnosis

- Nonalcoholic steatohepatitis, acute or chronic viral hepatitis, drug-induced liver injury, fulminant Wilson’s disease, autoimmune liver disease, alpha-1 antitrypsin deficiency, pyogenic hepatic abscess, ascending cholangitis, and decompensation associated with hepatocellular carcinoma.

Diagnosis can be confirmed on liver biopsy to help rule out other causes but lab findings as stated above in clinical context of heavy alcohol use is enough to make the diagnosis.

 

Assessing severity

There are several scoring systems used which helps decide whether corticosteroids should be initiated.  Lille score is designed to help decide if corticosteroids could be stopped after 1 week.

Maddrey’s discriminant function is calculated as [4.6×(patient’s prothrombin time−control prothrombin time, in seconds)]+serum bilirubin level, in milligrams per deciliter. A value of more than 32 indicates severe alcoholic hepatitis and is the threshold for initiating corticosteroid treatment

 

One study showed that patients with a Maddrey’s discriminant function of 32 or more and a Glasgow alcoholic hepatitis score of 9 or more who were treated with corticosteroids had an 84-day survival rate of 59%, as compared with a 38% survival rate among untreated patients.

The Lille score can be used to decide whether or not to stop corticosteroid treatment after 7 days. Al lille score greater than 0.45 indicates a lack of response and a 6 month survival rate of <25%

MELD score is useful as some patients may eventually become transplant candidates.

 

Management

- Management of alcoholic hepatitis includes both general treatment for decompensated liver disease and specific treatment for underlying disease.

- Management should include treatment of ascites with salt restriction and diuretics and encephalopathy with lactulose

- Patients should have workup for bacterial infection such as pneumonia, spontaneous bacterial peritonitis, and urinary tract infection blood and urine cultures, cell count, culture of ascitic fluid if present, and chest radiography.

- Enteric feeding should be initiated with daily protein intake of 1.5 g/kg even in setting of hepatic encephalopathy as these patients tend to be anorectic. Thiamine supplementation should also be given.

- It is also important to be wary of alcohol withdrawal which should promptly be treated with short acting benzodiazepines despite their risk of hepatic encephalopathy.

 

- The cornerstone of treatment as with all other alcoholic liver disease is abstinence and psychosocial support should be provided for patients. There is no evidence regarding efficacy of craving-reducing medications such as acamprosate and naltrexone in patients with alcoholic hepatitis. However, baclofen has been reported to promote short term abstinence in active drinkers with alcoholic cirrhosis.

 

- For patients with a Maddrey’s discriminant function of 32 or more in absence of sepsis, hepatorenal syndrome, chronic hepatitis B infection and GI bleeding should be treated with corticosteroids to curb inflammation. The most common corticosteroid therapy for alcoholic hepatitis is prednisolone at a dose of 40 mg per day for 28 days. At the end of the course of treatment, the prednisolone can be stopped all at once, or the dose can be gradually tapered over a period of 3 weeks.

 

- Pentoxifylline, a phosphodiesterase inhibitor, has been shown to reduce short term mortality in randomized control trials. The exact mechanism of this effect is not clear but it is speculated to be related to the prevention of hepatorenal syndrome.

 

- There has been conflicting results regarding use of Anti-TNF agents which have also been shown to increase risk of infection and death. As such, these agents are not standardly used.

 

- Alcoholic hepatitis is an absolute contraindication to liver transplant given the patient’s active alcohol abuse. A period of abstinence (6 months) is required before a patient with alcoholic hepatitis can be eligible for transplantation.

 

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