From the Guidelines
The diagnosis of alcoholic hepatitis is based on a combination of clinical, laboratory, and sometimes histological findings, with key criteria including onset of jaundice within 8 weeks of last period of drinking, heavy drinking (> 40 g/day) for more than 6 months, serum bilirubin > 3.0 mg/dL, serum AST > 50 IU/L but < 400 IU/L, and serum AST/ALT ratio > 1.5, as recommended by the most recent guidelines 1.
Key Diagnostic Criteria
- Onset of jaundice within 8 weeks of last period of drinking
- Heavy drinking (> 40 g/day) for more than 6 months
- Serum bilirubin > 3.0 mg/dL
- Serum AST > 50 IU/L but < 400 IU/L
- Serum AST/ALT ratio > 1.5
Laboratory and Histological Findings
- Elevated serum aminotransferases (AST typically higher than ALT)
- Elevated bilirubin
- Leukocytosis
- Coagulopathy
- Liver biopsy can confirm the diagnosis by showing hepatocyte ballooning, neutrophilic infiltration, Mallory-Denk bodies, and steatosis
Severity Assessment
- The Maddrey's Discriminant Function (DF) is commonly used to assess severity, with a score ≥32 indicating severe disease
- Other scoring systems include the MELD score, Glasgow Alcoholic Hepatitis Score, and ABIC score
Importance of Early Recognition
- Severe alcoholic hepatitis carries a high mortality rate
- Treatment options include corticosteroids (such as methylprednisolone 32 mg daily) for severe cases and nutritional support for all patients, as recommended by recent guidelines 1
Recent Guidelines and Recommendations
- The French Association for the Study of the Liver and the French Alcohol Society clinical guidelines recommend using the term ‘symptomatic alcoholic hepatitis’ for patients presenting with alcoholic hepatitis with jaundice and associating the adjective ‘severe’ with a Maddrey score above 32 and ‘moderate’ with a score below 32 1
- The Lille score must be calculated on the seventh day of treatment to identify patients not responding to treatment, and patients with a Lille score ≥ 0.45 are considered treatment non-responders 1
From the Research
Criteria to Diagnose Alcoholic Hepatitis
The diagnosis of alcoholic hepatitis (AH) is based on the appropriate alcohol intake history and is supported with clinical and histological features, and several scoring systems 2.
Histologic Features
Histologic features associated with the severity of AH include:
- Degree of fibrosis
- Degree of neutrophil infiltration
- Type of bilirubinostasis
- Presence of megamitochondria 3
Scoring Systems
Several scoring systems are used to diagnose and predict the prognosis of AH, including:
- Maddrey discriminant function (>32 indicates severe AH) 4
- Lille score (>0.45 indicates non-response to corticosteroid therapy) 4
- Alcoholic Hepatitis Histologic Score (AHHS) 3
- Laennec staging system (evaluates fibrosis) 5
Clinical Features
Clinical features that support the diagnosis of AH include:
- History of alcohol intake
- Clinical presentation (e.g. jaundice, ascites)
- Laboratory tests (e.g. liver function tests, bilirubin levels) 2
Prognostic Factors
Prognostic factors for AH include: