Alcoholic Hepatitis¶
Julie Cui, Alex Wiles
Background¶
- Acute onset of rapidly progressive jaundice in pt with heavy EtOH intake (>40g in females or >60g in males EtOH/day for >6 mos, or within <60 days of abstinence)
- May present after they have quit drinking due to immunosuppressive effects of alcohol
Evaluation¶
-
AST >60, AST/ALT >1.5, both values <400 IU/L; TBili >3.0 mg/dL, documentation of heavy EtOH use until 8 weeks prior to presentation
-
Prognostication with Maddrey’s Discriminant Function: 4.6 * (PTpt – PTctrl) + Tbili
- Maddrey > 32 = poor 30d prognosis & may benefit from steroids (see below)
-
RUQ U/S to rule out obstructive cause of jaundice
-
Biopsy is not typically required but will show neutrophilic lobular inflammation, hepatocyte ballooning, steatosis, and pericellular fibrosis.
-
Phosphatidylethanol (PEth) level is a biomarker of ethanol consumption over ~ 4wks; >20 ng/mL can indicate chronic moderate/heavy alcohol intake
- A single episode consumption can result in detectable Peth for up to 12 days. Can be elevated for months with regular heavy alcohol intake
- EtOH levels may be negative unless acutely intoxicated
Management¶
-
Supportive Care is essential! Consult nutrition, start high protein, high calorie diet, high dose Thiamine x 3d, Folate, MVI
-
Full infection workup (CXR, UA, BCx, paracentesis) regardless of symptoms
-
Steroids: STOP-AH Trial (NEJM 2015) showed improved mortality at 28 days but not at 90 days in patients with Maddrey > 32 who received steroids; the decision to treat is very nuanced and should be discussed with hepatology attending.
- Prednisolone 40mg daily for pts who meet above criteria
- Contraindications to steroids include: presence of infection (must rule out first including TB, uncontrolled GI bleeding, AKI w/ Cr >2.5 mg/dL)
- The Lille score can be used to guide continuation of steroids after 7 d of therapy
- NAC can be considered as adjunctive therapy to steroids and may decrease 30-day mortality, though has not demonstrated longer mortality benefit at 3 or 6 months
-
Monitor on CIWA
- Psychiatry consultation as appropriate, consideration of medical therapy (see “Substance Use Disorders” section in psychiatry)