Alcoholic Hepatitis

Ekaterine Labadze MD
Alcoholic Hepatitis

Alcoholic hepatitis is a
syndrome of progressive
inflammatory liver injury
associated with long-term
heavy intake of ethanol.
Signs and symptoms

Patients who are severely affected present with:

• subacute onset of fever,
• hepatomegaly,
• leukocytosis,
• marked impairment of liver function (eg, jaundice, coagulopathy)
• manifestations of portal hypertension (eg, ascites, hepatic
encephalopathy, variceal hemorrhage).
• However, milder forms of alcoholic hepatitis often do not cause
any symptoms.
2010 AASLD screening and diagnostic
recommendations for ALD

practice guideline includes the following recommendations for screening and

diagnosis :

• After discussion of alcohol use with the patient, if abuse or excess use is
suspected, screen the patient for alcohol abuse using a structured questionnaire
such as the Alcohol Use Disorders Identification Test (AUDIT)
• If the patient's history or a screening test is positive for alcohol abuse, use
laboratory testing to verify the diagnosis of ALD and rule out other
considerations
• If ALD is present, examine the patient for evidence of other alcohol-related
organ damage
Physical examination

• Patients with alcoholic hepatitis are commonly febrile with tachycardia.

• Mild tachypnea with primary respiratory alkalosis may be observed.
• The liver is usually enlarged, often with mild hepatic tenderness.
• Hepatomegaly results from both steatosis and swelling of the injured
hepatocytes.
• Manifestations of hepatic failure or portal hypertension may include
scleral icterus with darkening of the urine, splenomegaly, asterixis (a
flapping tremor characteristic of metabolic encephalopathies),
peripheral edema, and bulging flanks with shifting abdominal dullness
(indicating the presence of ascites).
Differential Diagnoses

• Common considerations in alcoholic patients with jaundice include

chronic pancreatitis with biliary strictures and pancreaticobiliary
neoplasms.
• Changes in the mental status of patients with alcoholic hepatitis do not
always imply the presence of hepatic encephalopathy. Other conditions
(eg, subdural hematomas) should be excluded by obtaining a computed
tomography (CT) scan of the brain.
• Chronic Pancreatitis
• Hepatitis B
• Hepatitis C
Diagnosis

• The diagnosis of alcoholic hepatitis is straightforward and requires no

further diagnostic studies in patients presenting with a history of alcohol
abuse, typical symptoms and physical findings, evidence of liver
functional impairment, and compatible liver enzyme levels. In milder
cases of alcoholic hepatitis, a mild elevation of the aspartate
aminotransferase (AST) level may be the only diagnostic clue.
• In August 2012, the Centers for Disease Control and Prevention (CDC)
expanded their existing, risk-based testing guidelines to recommend a 1-
time blood test for hepatitis C virus (HCV) infection in baby boomers—
the generation born between 1945 and 1965, who account for
approximately three fourths of all chronic HCV infections in the United
States—without prior ascertainment of HCV risk
Complete Blood Count

• A complete blood count (CBC) commonly reveals some degree of

neutrophilic leukocytosis with bandemia. Usually, this is
moderate; however, rarely, it is severe enough to provide a
leukemoid picture.
• Alcohol is a direct marrow suppressant, and moderate anemia may
be observed. In addition, alcohol use characteristically produces a
moderate increase in the mean corpuscular volume.
• Thrombocytosis may be observed as part of the inflammatory
response; conversely, myelosuppression or portal hypertension
with splenic sequestration of platelets may produce
thrombocytopenia.
Screening Blood Tests

• Hepatitis B surface antigen (HBsAg) detects hepatitis B

• Anti–hepatitis C virus by enzyme-linked immunosorbent assay (ELISA) detects
hepatitis C
• Ferritin and transferrin saturation detect hemochromatosis
• Marked elevation of aminotransferase levels should raise concern for viral hepatitis
or drug hepatotoxicity; in particular, people who are alcoholics may develop severe
liver necrosis from standard therapeutic doses of acetaminophen
• Rapid deterioration of liver function should raise the possibility of hepatocellular
carcinoma (HCC), which can be tested for by determination of alpha-fetoprotein
(AFP) levels as well as findings on an imaging study of the liver
• Jaundice with fever can be caused by gallstones producing cholangitis and is
suggested by a disproportionate elevation of the alkaline phosphatase (ALP) level
Liver Tests

• In most patients, the aspartate aminotransferase (AST) level is

moderately elevated, whereas the alanine aminotransferase (ALT) level
is in the reference range or only mildly elevated. This is the opposite of
what is observed in most other liver diseases.
• Alkaline phosphatase (ALP) level elevations are typically mild in persons
with alcoholic hepatitis. Levels greater than 500 U/L occur in a small
percentage of patients, but abnormalities of this magnitude suggest a
coexisting infiltrative or biliary obstructive process
• The gamma-glutamyl transpeptidase (GGTP) level is elevated markedly
by alcohol use. Although a normal value helps to exclude alcohol as a
cause of liver disease, an elevated level is of no value in distinguishing
between simple alcoholism and alcoholic hepatitis.
Ultrasonography

• In general, real-time ultrasonography is the preferred imaging

study in evaluating patients with suspected alcoholic hepatitis,
because it is inexpensive, noninvasive, and widely available.
• On ultrasonograms, the liver in patients with alcoholic hepatitis
appears enlarged and diffusely hyperechoic. Features suggestive
of coexistent portal hypertension and/or cirrhosis include the
presence of varices, splenomegaly, and ascites.
• Ultrasonography is also helpful in excluding gallstones, bile duct
obstruction, and hepatic or biliary neoplasms. Jaundice with fever
can be caused by gallstones producing cholangitis;
Liver Biopsy

Liver biopsy is not always required in the evaluation of alcoholic hepatitis,

but it may be useful in establishing the diagnosis, in determining the
presence or absence of cirrhosis, and in excluding other causes of liver
disease.
• Percutaneous biopsy can be performed at the bedside by an
experienced practitioner, usually a gastroenterologist or a hepatologist.
Usually, a biopsy should be avoided in the presence of severe
thrombocytopenia or coagulopathy because of the risk of serious
(possibly fatal) hemorrhage.
• Transjugular liver biopsy. If biopsy information is considered essential
and the risk of percutaneous biopsy appears excessive, an alternative
approach is to perform a biopsy angiographically via a catheter passed
into the hepatic vein under fluoroscopic guidance
Treatment & Management

• In most patients with alcoholic hepatitis, the illness is mild. The short-
term prognosis is good, and no specific treatment is required.
Hospitalization is not always necessary.
• Alcohol use must be stopped, and care should be taken to ensure good
nutrition; providing supplemental vitamins and minerals, including folate
and thiamine, is reasonable. Patients who are coagulopathic should
receive vitamin K parenterally.
• In contrast, patients with severe acute alcoholic hepatitis are at a high
risk of early death, at a rate of 50% or greater within 30 days.
• Glucocorticosteroids are widely used for this purpose, although their
benefits have not been proven unequivocally.
Diet and Nutritional Support

• For patients with milder alcoholic hepatitis, a general diet

containing 100 g/d of protein is appropriate.
• Provide supplemental multivitamins and minerals, including folate
and thiamine.
• Salt restriction may be required in patients with ascites.
Pharmacotherapy

• Use of medications in alcoholic hepatitis has been considered

controversial. Many treatments discussed in the Medication section are
still investigational.
• Naltrexone or acamprosate may be used, in addition to counseling, to
assist patients who have achieved abstinence to avoid relapsing.
• Prednisolone and pentoxifylline are recommended for the treatment of
severe alcoholic hepatitis, but uncertainty about their benefit persists.
• Patients with mild forms of alcoholic hepatitis should not be treated
with steroids.
Liver Transplantation

• Orthotopic liver transplantation is widely used in patients with end-stage liver

disease.
• Most patients with active alcoholic hepatitis are excluded from transplantation
because of ongoing alcohol abuse.
• Patients must abstain from alcohol for at least 6 months before they can be
considered for transplantation, and a thorough psychosocial evaluation must
demonstrate that patients have a low likelihood of reverting to alcohol abuse.
• Patients with alcoholic hepatitis may be informed that their liver injury can be
expected to subside, and liver function will improve following at least 6 months
of abstinence.
• If they still develop cirrhosis and its complications, they can be considered for
transplantation if they remain committed to sustained abstinence. T
Medication Summary

Use of medications in alcoholic hepatitis has been considered controversial. Many

treatments discussed in this section remain investigational.
The 2010 American Association for the Study of Liver Diseases (AASLD) alcoholic
liver disease (ALD) guideline does indicate that the following drugs may be
considered :
• Naltrexone or acamprosate may be used, in addition to counseling, to assist
patients who have achieved abstinence to avoid relapsing.
• Prednisolone should be considered, unless steroids are contraindicated, in
patients with severe disease .Pentoxifylline may also be considered, especially
if prednisolone cannot be used. In a clinical trial, the use of prednisolone and
pentoxifylline in combination did not result in improved 6-month survival over
use of prednisolone alone in patients with severe alcoholic hepatitis.
Questions

• What is alcoholic hepatitis?

• What are the signs and symptoms of alcoholic hepatitis?
• How is alcoholic hepatitis diagnosed?
• What are the etiologic factors of alcoholic hepatitis?
• What are the differential diagnoses for Alcoholic Hepatitis?
• What is the role of lab testing in the evaluation of alcoholic hepatitis?
• What is the role of imaging studies in the evaluation of alcoholic
hepatitis?
• What are the treatment options for alcoholic hepatitis?