Alcoholic Hepatitis

 3 Histological Stages

• Simple steatosis (usually reversible w/ abstinence in 4-6 wks)
• Steatohepatitis (steatosis + neutrophil infiltration + Mallory-Denk bodies)
• Steato-fibrosis (extreme is cirrhosis)

MELD SCORE [calculate with mdcalc]

Model for End-Stage Liver Disease (MELD) score is a prognostic scoring system used to predict 3-month mortality due to liver disease

MELD scores range from 6 to 40; the higher the score, the higher the 3-month mortality related to liver disease

MDF SCORE  [calculate with mdcalc]

Maddrey Discriminant Function (MDF) score is a measure of disease prognosis in alcoholic hepatitis (AH) used to identify patients at highest risk of mortality and determine the need for initiation of pharmacologic treatment.

Alcohol Related Hepatitis

An acute inflammatory syndrome that develops in the setting of chronic liver inflammation w/ alcohol use.

Risk Factors

Amount of alcohol, duration of alcohol use (>5-10 yrs for cirrhosis), gender (F>M), ethnicity (↑risk in AA & Hispanics), HCV (>30x ↑risk for cirrhosis), genetic mutations (PNLPA3) and obesity

Clinical Presentation

Hepatomegaly, jaundice, ascites, encephalopathy and fever. 

Of note: alcohol related hepatitis can lead to portal HTN and varices and ascites in the absence of cirrhosis due to hepatic swelling and portal venous obstruction.

Diagnosis

• Often cholestatic LFTs (↑alk phos) with elevated AST & ALT (usually <300), typically in >2:1 ratio).
• ALT can be normal if vitamin B6 deficiency.
• ↑WBC

Treatment for Alcohol Related Hepatitis

• If MDF ≥ 32 (Or MELD >20) and/or presence of encephalopathy commence steroids: prednisolone 40mg/d for 4 weeks +/- taper x 2-4 weeks. Adding NAC may be beneficial, but ask for GI input before starting. Consider pentoxyfylline if steroids are contraindicated. Consult hepatology for consideration of early liver transplant if appropriate.
• Contraindications to prednisolone: active infection, chronic HBV/HCV, GIB, pancreatitis, renal failure.
• Lille Score: composite score of age, Cr, alb, PT, Tbili on day 0 and Tbili on day 7 of steroids. Calculate on day 7 to evaluate response to steroids; a score >0.56 indicates lack of response at 7 days → can discontinue steroids.
• Supportive therapy: monitor for infection, consider PPI/ H2RA, monitor for signs of HRS and avoid nephrotoxic drugs, hold beta blockers if MDF ≥ 32 due to incidence of AKI.
• Nutrition therapy: MVI, thiamine, folate, enteral feeding; nutrition independently decreases mortality.
• Only abstinence from alcohol and liver transplant are effective for long term treatment of alcohol related hepatitis. At discharge, patients should receive medication assisted therapy (acamprosate 666 mg TID, naltrexone 50mg QD, baclofen 5- 10mg TID, gabapentin 600mg TID)