What is the management for a patient with acute alcoholic hepatitis who was discharged on methylprednisolone (corticosteroid) 3 days ago and now presents with worsening liver function (elevated total bilirubin) and leukocytosis (elevated white blood cell count) without fever or chills, and with large volume ascites?

Management of Acute Alcoholic Hepatitis with Worsening Clinical Parameters and Large Volume Ascites

The patient requires immediate hospitalization with discontinuation of methylprednisolone, thorough infection workup, and therapeutic paracentesis for the large volume ascites. 1

Assessment of Current Status

This patient presents with concerning features suggesting treatment failure and possible infection:

• Worsening liver function (bilirubin increased from 23.46 to 28.58)
• Significant leukocytosis (WBC increased from 28 to 40.3)
• New large volume ascites
• Recent discharge on corticosteroids (methylprednisolone)

Immediate Management Steps:

1. Hospitalize the patient

   • Admit to intermediate care or ICU depending on severity assessment 1

2. Discontinue methylprednisolone

   • The rising WBC and worsening liver function suggest steroid non-response (Lille score likely ≥0.45) 1
   • Continuing steroids in non-responders increases infection risk without benefit 2

3. Perform thorough infection workup

   • Blood cultures (2 sets)
   • Urine culture
   • Diagnostic paracentesis with cell count, culture, and neutrophil count 1
   • Chest X-ray
   • Consider CT abdomen/pelvis to evaluate for other sources of infection

4. Therapeutic paracentesis for large volume ascites

   • Remove 4-6 liters with albumin replacement (6-8g albumin per liter removed) 1
   • Ascitic fluid analysis: cell count with differential, culture, protein, albumin

5. Empiric antibiotic therapy

   • Start cefotaxime 2g IV q8h or similar third-generation cephalosporin 1
   • The high WBC strongly suggests infection, likely spontaneous bacterial peritonitis (SBP)
   • Threshold for empiric antibiotics should be low even without fever 1

Additional Management Considerations

Nutritional Support

• Provide high-protein (1.5 g/kg/day) and high-calorie (40 kcal/kg/day) nutrition 1
• Consider enteral nutrition if oral intake is inadequate

Fluid and Electrolyte Management

• Strict fluid balance monitoring
• Sodium restriction (<2g/day)
• Diuretic therapy after infection is ruled out/controlled
• Monitor for hepatorenal syndrome

Evaluation for Liver Transplantation

• Assess candidacy for liver transplantation if patient meets criteria
• Consider early referral to transplant center if severe disease with poor prognostic indicators

Monitoring and Follow-up

• Daily liver function tests, CBC, renal function
• Monitor for signs of hepatic encephalopathy
• Repeat paracentesis if clinical deterioration occurs
• Assess response to antibiotics within 48-72 hours

Prognosis and Considerations

The patient's clinical deterioration shortly after discharge with rising bilirubin and WBC count suggests:

1. Non-response to corticosteroid therapy (Lille score likely ≥0.45)
2. Probable infection complicating alcoholic hepatitis
3. Poor short-term prognosis without aggressive intervention

Common Pitfalls to Avoid

1. Continuing corticosteroids despite evidence of non-response

   • Steroids increase infection risk in non-responders 2
   • Discontinue if Lille score ≥0.45 at day 7 1

2. Delaying antibiotic therapy while awaiting culture results

   • Empiric antibiotics should be started immediately with this degree of leukocytosis 1

3. Inadequate volume of paracentesis

   • Large volume paracentesis with albumin replacement is needed for symptomatic relief 1

4. Failing to consider infection as the cause of deterioration

   • Infection is common in alcoholic hepatitis and may be the reason for clinical worsening 2

This patient's rapid deterioration after discharge requires urgent intervention focusing on infection control, ascites management, and reassessment of overall treatment strategy.