FIRM A YELLOW

SHOW AND TELL

History of Presenting Illness

■ 52 year-old man with a PMH of HIV, VL-undetectable, hepatic steatosis- likely alcohol-
induced, cc: feeling like he was withdrawing.
■ Sweating, body pains, has hand tremors of B hands, watery stools
■ Last drink 3 days from his admission at the ED
Past Medical History
■ HTN, Hepatic steatosis, alcohol-related
■ Allergies- doxycycline
■ PSH: Smoker- 6 sticks/day x 14 years, cocaine 3-5x/week x 20 years, 2 bottles of gin/day x 20 years
■ Medications: nifedipine 30 mg/tab 1 tab OD, Biktarvy OD, B12, folate, gabapentin 300 mg/tab 1 tab
OD
■ FH: father- alcohol use disorder, mother, brother- HTN, DM
ED Course

■ Received at the ED with VS: HR 82, T 36.8, RR 18, BP 169/80

■ Patient's exam notable for icteric sclerae, abdominal distention and tenderness, UE
tremors
■ Bedside ultrasound : intraperitoneal fluid,
■ Diagnostic paracentesis performed draining 20cc of straw-colored fluid
■ lorazepam 2 mg given for likely mild-moderate EtOH withdrawal
 Physical Exam
■ General:  Alert and oriented, No acute distress.  
■ HENT:  Normocephalic, icteric sclerae.
■ Neck:  Supple, Non-tender, No carotid bruit, No jugular venous distention.  
■ Respiratory:  Lungs are clear to auscultation, Respirations are non-labored, Breath sounds are equal, Symmetrical
chest wall expansion.  
■ Cardiovascular:  Normal rate, Regular rhythm, significant pitting BLE edema .  
■ Gastrointestinal:  Distended abdomen, hepatomegaly noted, no tenderness, no rebound or guarding, bowel
sounds present
■ Musculoskeletal   Normal range of motion, Normal strength. 
■ Integumentary:  Warm, Dry
■ Neurologic:  A and O 3x, mild tremors with outstretched hands. No asterixis. Normal gait.
■ Cognition and Speech:  Oriented, Speech clear and coherent, Functional cognition intact.  
■ Psychiatric:  Cooperative, Appropriate mood & affect.  
Labs and Imaging

■K 3.2, Cr 1, BUN10, Bil increased from 1.8 to 9.9

(total) with 5.8 conjugated bilirubin
■AP 234, GGT 525, AST/ALT 96/26, lipase 69 (stable)
■Mg 0.6, Alb 2.1
■WBC 2.9, Hg 9.5, MCV 101, Plts 19
■B12 2503, Folate 5
Labs and Imaging

■ CTAP 07/2020
Abnormal liver including fatty infiltration, periportal edema and multiple small hypodense
lesions. Findings likely reflect hepatitis. Diagnostic considerations for the small hypodense
masses include abscess as well as both benign and malignant masses. Gallbladder wall
thickening is a nonspecific finding but is probably reactive to the inflammatory process in
the liver.
■ high SAAG low protein consistent with portal hypertension
Yellow, hazy, peritoneal fluid RBC 4100, WBC 80, albumin 0.5, glucose 110, LDH 79, total
protein 1.2
 Floors: Assessment and Plan
■ Acute alcohol withdrawal, alcohol use disorder
-4 mg Ativan in the ED
-CIWA Protocol
-Thiamine, folic acid
■ Acute alcohol-related hepatitis
-Maddrey: 29, MELD-Na 21
-Continue monitoring LFT’s and Maddrey Score
■ Alcohol-related liver disease, likely cirrhosis
- repeat liver ultrasound, initiate SBP prophylaxis
 HIV
continue Biktarvy
 Assessment and Plan
■ Acute alcohol withdrawal
-CIWA 6, Ativan per protocol
■ Acute alcohol-related hepatitis
- Maddrey: 39
-Prednisolone 40 mg OD
■ Alcohol-related cirrhosis, Child C, Meld Na 18
- liver ultrasound: hepatopetal flow of blood in portal vein, cirrhotic morphology of liver,
hepatomegaly, splenomegaly
- SBP prophylaxis : will start due to BT> 3 and ascitic fluid prot <1.5- ciprofloxacin 500 mg OD
- hepatitis B vaccination inpatient
 HIV
-continue Biktarvy
 Assessment and Plan
■ Acute alcohol withdrawal
-CIWA 6, Ativan per protocol
■ Acute alcohol-related hepatitis
- Maddrey: 36, TB 9 on admission, downtrending to 7.9, DB 4.8, AST 128 to 78
-Prednisolone 40 mg OD x 7 days
■ Alcohol-related cirrhosis, Child C, Meld Na 18, with coagulopathy and thrombocytopenia
- liver ultrasound: hepatopetal flow of blood in portal vein, cirrhotic morphology of liver, hepatomegaly,
splenomegaly
- mild INR 1.65 -> INR 1.92 -> 1.87
- SBP prophylaxis : will start due to BT> 3 and ascitic fluid prot <1.5- ciprofloxacin 500 mg OD
- hepatitis B vaccination inpatient
- phytonadione
 HIV
-continue Biktarvy
Plan for discharge

■ Prednisolone 40 mg OD x 7 days, TCB on 7th day, Lille score

■ Ciprofloxacin 500 mg OD
■ SBIRT consult
■ Folate, thiamine
■ Follow up at GI clinic
ALCOHOLIC HEPATITIS-
DIAGNOSIS
■ Patient with long history of heavy alcohol use (>100 g >20 years)
■ Signs and symptoms: jaundice, anorexia, fever, tender hepatomegaly
■ Encephalopathy, signs of malnutrition
■ Testing for other causes of hepatitis is negative: viral hepatitis. Biliary
obstruction/ Budd Chiari syndrome
■ Fever or leukocytosis
■ Jaundice, moderately elevated aminotransferases 300-400 IU/mL
■ AST:ALT ratio>=2
■ Elevated serum total bilirubin 3-5 mg/dL
■ Elevated INR
ALCOHOLIC HEPATITIS-
PROGNOSTICATION
■ Get the Maddrey Score (mortality risk within the first month)
– >32: 35-45% mortality
■ MELD Na Score
ALCOHOLIC HEPATITIS-
PROGNOSTICATION
■ Get the Maddrey Score (mortality risk within the first month)
– >32: 35-45% mortality
■ MELD Na Score:
– 30-day mortality in hospitalized patients (Sn 86 Sp 81), 3-month survival (Sn 75,
Sp 75)

Adapted from: Wiesner, R, Edwards, E, Freeman, R, et al. Model for end-stage liver disease (MELD) and allocation of donor livers. Gastroenterology 2003; 124:91.
MANAGEMENT OF PATIENTS W/
ALCOHOLIC HEPATITIS

■ Nutritional support
– B1, B6, B9, B12, Vitamin K, adequate protein, enteral tube feeding> parenteral
■ Hydration – albumin for prerenal azotemia and cirrhosis
■ Protocol for alcohol withdrawal, counseling on the alcohol cessation
MANAGEMENT OF PATIENTS W/
ALCOHOLIC HEPATITIS
• Prednisolone 40 mg OD x 28 days then taper
• Methylprednisolone 32 mg IV if patient cannot tolerate PO
• Monitor with DF, total biluribin, Lille score
• Stop therapy in patients who do not improve after 1 week
Ramond MJ, Poynard T, Rueff B, Mathurin P, Théodore C, Chaput JC, Benhamou JP. A randomized trial of prednisolone in patients with severe alcoholic hepatitis. N
Engl J Med. 1992 Feb 20;326(8):507-12. doi: 10.1056/NEJM199202203260802. PMID: 1531090.
N Engl J Med 2015; 372:1619-1628
DOI: 10.1056/NEJMoa1412278
LIVER TRANSPLANTATION
■ Patients with severe alcoholic hepatitis who fail to respond to tx with glucocorticoids
■ Abstinence is an expectation for patients on transplant waiting lists
■ Alcohol relapse after transplant occurs in 10-30%

Model to Calculate Harms and Benefits of Early vs

Delayed Liver Transplantation for Patients With Alcohol-
Associated HepatitisLee B.P., Samur S., Dalgic
O.O., Bethea E.D., Lucey M.R., Weinberg E., Hsu
C., (...), Chhatwal J.
(2019)  Gastroenterology,  157  (2) , pp. 472-480.e5.
LIVER TRANSPLANTATION

Model to Calculate Harms and Benefits of Early vs

Delayed Liver Transplantation for Patients With Alcohol-
Associated HepatitisLee B.P., Samur S., Dalgic
O.O., Bethea E.D., Lucey M.R., Weinberg E., Hsu
C., (...), Chhatwal J.
(2019)  Gastroenterology,  157  (2) , pp. 472-480.e5.