Alcoholic (Steato)Hepatitis

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.

About

• 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

Aetiology

• 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

Host characteristics

• 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

Clinical

• 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

Differential

• Liver failure and hepatic encephalopathy
• Cholecystitis
• Acute Hepatitis A or B infection

Investigations

• ↓ 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

A GAH score greater than 9 indicates a poor prognosis, and suggests the the patient may benefit from steroid

Management

• 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