Alcoholic hepatitis

Alcoholic hepatitis is a clinical syndrome characterised by recent onset of jaundice and/or ascites in a patient with ongoing alcohol misuse.

The predominant cause of alcoholic hepatitis is alcoholic steatohepatitis, which is diagnosed histologically by the presence of steatosis, hepatocyte ballooning and inflammatory infiltrate with PMNs.

Presentation may include:

• progressive jaundice
• ascites
• fever 
• weight loss
• hepatolomegaly
• anorexia
• nausea and vomiting
• abdominal pain

Investigations:

• LFTs
• AST typically 2-6x upper limit of normal
• AST/ALT ratio >2
• bilirubin frequently raised
• clotting
• FBC
• screen for HBV, HCV, HIV
• abdominal US to exclude other causes of jaundice
• consider transjugular liver biopsy

Several scoring systems exist to assess prognosis (Maddrey's discriminant function, MELD, ABIC, Glasgow).  Maddrey's is the commonest:

Maddrey discriminant factor = (4.6 x prolongation of PT) + serum bilirubin (mg/dl) 

(NB in UK bili is given in micromol/l so needs to be divided by 17)

>32 indicates poor outcome.

Management of high-risk patients:

• prednisolone 40mg OD 
• or pentoxifylline (a phosphodiesterase inhibitor and TNF alpha inhibitor) 400mg TDS if patient septic
• ? enteral feeding
• ? n-acetylcysteine in patients with severe disease receiving steroids
• careful monitoring of renal function  
• careful watching for infection and prompt treatment if present

Complications

• GI bleeds requiring transfusion occur in around 20%
• encephalopathy occurs in around 20%
• hepatorenal syndrome

References
Amini, M. and Runynon, B. Alcoholic hepatitis 2010: A clinicians guide to diagnosis and therapy. World J Gastroenterol. 2010; 16(39): 4905-4912.
European Association for the Study of the Liver. EASL Clinical Practical Guidelines: Management of alcoholic liver disease. J Hepatology. 2012. 57: 399-420.
Menachery, J. and Duseja, A. Treatment of decompensated alcoholic liver disease. Int J Hepatol. Epub 2011; Jul 12.