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Alcoholic Hepatitis

Julie Cui, Alex Wiles


  • 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


  • 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


  • 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)

Last update: 2022-06-21 11:20:46