inpatient / gastroenterology

Alcoholic Hepatitis

Last Updated: 1/7/2023

# Alcoholic Hepatitis

-- Chart Check: calculate Maddrey Discriminant Function (MDF) and MELD
-- HPI Intake: travel, sick contacts, EtOH use, last drink, tylenol use
-- Can't Miss: infectious hepatitis, ALF, sepsis
-- Admission Orders: Labs - CBC, BMP, LFTs, coags, PEth
-- Initial Treatment to Consider: supportive care

-- History: *** travel, sick contacts, EtOH use, last drink, tylenol use
-- Clinical/Exam: *** nausea/vom, anorexia, malaise, fevers, weight loss, jaundice, RUQ pain
-- Data: *** ALT/AST (often 50-400 ranges with AST/ALT >1.5), Tbili (often >3)
-- Etiology/DDx: *** vrial hepatitis, cholangtitis, DILI, medication, ischemia, autoimmune hepatitis, Budd-Chiari

The patient's HPI is notable for ***. Exam showed ***. Labwork and data were notable for ***. Taken together, the patient's presentation is most concerning for ***, with a differential including ***.

-- f/u LFTs, PEth
-- Infectious workup - BCx, UA, CXR, hepatitis serologies (anti-HAV IgM and IgG, HBV surface Ag, surface IgG, Core IgM, HCV IgG with reflex PCR quant) - patients often present with SIRS, need to rule out infection
-- consult GI to help with steroid decision, nutrition to optimize
-- CIWA if c/w withdrawal

-- Steroid: *** (if acute infection rule out and MDF >32 or MELD >20, consider PO prednisolone 40mg/day vs IV methylpred 32mg daily, continue for 28 day course with 2-4 wek taper by 10mg q4 days, if Lille Score on day 7 is < 0.45, otherwise stop steroids; largely driven by a reduction in bilirubin)
-- Continue thiamine, folic acid
-- Consider NAC, pentoxifylline
-- Consider holding BB if MDF >32, risk of AKI
-- Alcohol cessation - often treatments for AUD (naltrexone)

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If You Remember Nothing Else

Alcoholic hepatitis can present in many ways, and often looks like an infection. Alcoholic hepatitis usually does not have AST or ALT levels above 400, and usually has a higher AST than ALT. Once an infectious etiology is ruled out, supportive care and steroids are the mainstay of treatments, though you should enlist the help of GI consultants because the decision is often nuanced.

Clinical Pearls

  • Alcohol-related hepatitis is an acute inflammatory syndrome that can occur at any stage of alcohol-related liver disease (ALD)
  • Alcohol-related hepatitis can present with few symptoms all the way up to liver failure
  • Alc hep often presents with SIRS and looks like an infection
  • The decision to treat with steroids is nuanced - no great treatments; Prednisolone is used for alcoholic hep since it is not metabolized by the liver
  • If MDF >32 indicates severe alc hep with 1-month mortality of 20-50% 
  • If AST >400 should increase suspicion for DILI or ischemic hepatitis
  • HAV is usually symptomatic, whereas HBV and HCV morse commonly subclinical in the acute phase but are more likely to progress to chronic disease
  • Treatment of HAV and HBV is supportive unless liver failure
  • Vaccinate against HAV if MSM, IVDU, chronic liver disease, travel, homeless
  • Before treating for HCV, need to confirm no cirrhosis, HIV, HepB, pregnancy
  • Steatosis associated with alcohol use can be fully reversible with 4-6 weeks of abstinence

Trials and Literature

  • Alcohol Associated Hepatitis - Review (NEJM, 2022)
  • STOP-AH Trial - in alc hep with MDF >32, steroids improved mortality at 28 days (not significant), but not at 90 days or 1 year; pentoxifylline did not improve survival at any time (NEJM, 2015)

Other Resources