Alcoholic Hepatitis

- The actual amount is not known

- History of heavy alcohol use (>100g per day)
o 10g = 12oz beer // 8oz of malt liquor // 5oz of wine // 1.5oz of spirit
- Determine severity: MELD (Model for End Stage Liver Disease), others are:
o Glasgow
o ABIC
o Lille
o Child-Pugh
- Maddrey Discriminant Function
o Disease severity and mortality risk
 4.6 x [PT – control PT] + Serum Bili
o >= 32 low short term mortality, benefit from steroids
o Sensitivity 86, Specificity 48
- MELD - predict severity
o Score ranges from 6 to 40
o Uses: Age, Cr, Bili, INR, HD in the last 24hrs or twice in the past week,
 If HD is performed, set Cr @ 4
o One study >11 performed as well as positive DF in predicting 30 day mortality
 Sensitivity: 86, Specificity 81
o Another study >21
 Sensitivity 75, Specificity 75
o MELD increase of +2 while hospitalized in a week, predict in-hospital mortality
- Glasgow
o Age, Bili, BUN, PT, and WBC
o One study, >9 lower sensitivity but higher specificity than DF
 Sensitivity 81, Specificity 61
 Glucocorticosteroids have higher survival rates
- Lille
o Age, Cr >1.3 or Cr clearance <40, albumin, Prothrombin Time, Bili (day 7 – day
0)
o Score >0.45, higher mortality of 6 months
Symptoms/Presentation/Complications
- PE: hepatomegaly, jaundice, anorexia, fever, RUQ-epigastric pain, ascites, proximal
muscle wasting
- Multi-system/multi-organ failure
o Renal failure
- Hepatic Encephalopathy
- Gastric/esophageal ulcers/varices
- Typically volume down, poor hydration
o Give Albumin > Crystalloids
 - Typically poor nutrition
o Make sure they get calories, protein, vitamins (thiamine, folate, pyridoxine),
minerals (phos, mg)
- Poor liver function (elevated INR)
o Give Vitamin K, parenteral is preferred, oral is not well absorbed

Lab test
- Liver Enzymes: Typically <300
- AST:ALT >2
- Elevated Bili
- Elevated GGT
- Leukocytosis with a predominance of neutrophils
- Elevated INR

Complications of cirrhosis
- Pt may have underlying cirrhosis, portal HTN, hepatic encephalopathy, ascites, variceal
bleeding
- Renal Failure

Increase survival?
- Quit alcohol. Now.
o Treat for potential withdrawal

Treatment
- If they have HE?? Lactulose, Rifaximin -> 2 to 4 bowel movements a day
- Ascites?? Get an US, Diagnostic tap, therapeutic tap.
o Infectious? Fever, WBC, Worsening mental state, hemodynamic instability
o SBP? Treat it, get cell count, culture, total protein, albumin
o Don’t forget blood culture, urine culture, sputum culture – if productive cough,
CSF culture – meningitis concerns
- Critically ill: cannot protect airway?? Intubation
- Glucocorticosteroids: Prednisolone 40mg daily
o Prednisone has to be converted to prednisolone…by what? The liver
 Guess what can be impaired? The liver.
o IV methylprednisolone 32mg daily if cannot tolerate PO
o Duration: 28 days
 16 day taper: 10mg every 4 days, until 10mg decrease 5mg every 3 days
 o Stop if no improvement in 7 days
- Pentoxifylline in severe alcoholic hepatitis (TNF inhibitor)
o May provide more benefit for certain subgroups (i.e. renal failure)
o Dosage: 400mg TID, Cr Clearance <30 – 400mg daily
o Bili <5? Stop therapy
o Dyspepsia?? Dec PO intake? Stop it
- Studies show, substituting pentoxifylline if they failed steroids doesn’t help
- Discontinue nonselective beta blockers – increased risk of AKI
- Possible treatments
o NAC
 No difference in 6 month mortality from prednisolone vs prednisolone +
NAC
 Mortality is higher at 1 month in prednisolone alone
o GCSF (granulocyte colony stimulating factor)
 Non blinded, randomized trial of 46 patients
 GCSF+pentoxifylline > pentoxifylline @ 90 days
o Oxandrolone
 No response of pentoxifylline at 10-14 days, start this
 Anabolic steroid 40mg daily for a total of 30 days
- Ineffective treatments
o Anti-TNF antibodies
o Anabolic steroids
- Transplant
Trials
- STOPAH trial: 28 day mortality was reduced if you received glucocorticosteroids
o Long term data is more limited, but do not show benefit
Mortality