The ALT is often less than 300 but do not let this fool you. This is a serious disease with significant mortality. Be aware of Maddrey's score based on Prothrombin time and bilirubin and consider steroids when the score > 32.
- Fever jaundice and coagulopathy
- Tender hepatomegaly in a known drinker
- There are many similarities with NASH
- Seen in 10-30% after 15-20 years of heavy drinking
- There is acute liver inflammation ↑ AST ↑ TNF-alpha
- Often on background of alcoholic steatosis
- Alcohol is hepatotoxic but most alcoholics do not get cirrhosis
- ↑ AST but the limited rise in ALT due to a deficiency of pyridoxal 5' phosphate seen in alcoholics
- Genetic variability alcohol metabolising enzymes
- Genetic variability in response to damage e.g. Pro-inflammatory genes or Predisposition to autoimmunity, Obesity, Gender
- Co-factors e.g. raised Iron, drugs, toxins, a1AT deficiency
- Co-Infection with hepatotropic viruses
- Malaise, anorexia, weakness
- Fever < 40°C + Jaundice + Sudden onset tender hepatomegaly
- Known alcohol abuse and drinking heavily
- Look for encephalopathy and ascites and RUQ pain
- Chronic signs - palmar erythema, dupuytrens contracture
- Enlarged parotids, malnutrition, small testes, gynecomastia, bruising
- Hepatic encephalopathy/coagulopathy over the first 1-3 weeks in hospital
- Asterixis, unable to draw 5 pointed stars, drowsiness
- Reversal day/night sleeping pattern, Coma
- Liver failure and hepatic encephalopathy
- Acute Hepatitis A or B infection
- ↓ Hb, ↓ Platelets ↑ WCC, IgA is typically ↑
- ALT ↑ but less than 300 iu/L
- AST/ALT ratio is usually ↑ x 2-3
- If ALT ↑ ↑ look for another cause ↑ GGT is common
- ↑ prothrombin time which does not respond to vitamin K
- ↑ ammonia ↓ albumin
- EEG shows an encephalopathic pattern with slow-wave activity
- Check coexisting viral hepatitis HBV HCV
- USS - fatty liver
- Biopsy - hepatocellular ballooning which contains Mallory bodies, fibrosis. Bridging hepatic fibrosis suggests progression to cirrhosis.
Prognosis: GAHS/Maddrey's score
- As assessment of severity call the discriminant function is useful in patients with alcoholic hepatitis and is also known as Maddrey's score assessed AFTER Vitamin K
- Maddrey's (modified) discriminant factor
(4.6 x PT-control) + (serum bilirubin umol/l /17)
>32 implies >50% mortality at 1 month
- A GAHS score of 9 or more identify patients most at risk of death. A score of 9 or more can be used either on day 1 (admission day) or day 6-9.
Glasgow Alcoholic hepatitis score
|Age (yrs) ||<50||>50|
A GAH score greater than 9 indicates a
poor prognosis, and suggests the
the patient may benefit from steroid
- Stop alcohol with significant benefits of 6-12 months of abstention.
- Thiamine 200 mg daily and Pabrinex (2x3) iv
- Adequate protein nutrition (1.5g/kg ENTERALLY)
- Anticipate alcohol withdrawal - Chlordiazepoxide to prevent Delirium Tremens
- Antibiotics to prevent bacterial translocation
- Correct electrolytes, K+, Mg+
- Oral lactulose and enemas
- Nutritional assessment and NG or oral feeding
- Patients with severe alcoholic hepatitis MDF > 32 (modified discriminant function) or more specifically GAHS>9 benefit from a corticosteroid, and perhaps pentoxifylline. Day 28 survival for patients with GAHS <9 is 87 % whereas if GAHS >9 survival drops to 46% in absence of treatment.
- Pentoxifylline 400 mg TDS for 4 weeks po reduces mortality. The main benefit appears to be related to a significant decrease in the risk of developing hepatorenal syndrome
- Prednisolone 30 mg od for 30 days, followed by a reducing dose and withdrawal over the subsequent 2-4 weeks.
- Orthotopic liver transplantation is used in patients with end-stage liver disease but those with active alcoholic hepatitis are usually excluded from transplantation because of ongoing alcohol abuse. Patients usually must abstain from alcohol for at least 6 months before they can be considered for transplantation.
- Consider 6 monthly serum alpha-fetoprotein level and USS to look for early hepatocellular carcinoma