What is the appropriate treatment plan for a patient presenting with thrombocytopenia, coagulopathy, hypokalemia, hypomagnesemia, elevated liver enzymes, and a history of chronic alcohol use?

Management of Alcoholic Hepatitis with Thrombocytopenia

The patient requires immediate hospital admission for management of alcoholic hepatitis with severe thrombocytopenia, electrolyte abnormalities, and elevated liver enzymes. 1

Initial Assessment and Stabilization

• Severity assessment: Calculate Maddrey's Discriminant Function (MDF) and MELD score to determine prognosis and guide treatment

  • With AST 293, ALT 222, bilirubin 1.5, and INR 1.1, this represents alcoholic hepatitis of moderate severity
  • Blood alcohol level of 330 indicates acute intoxication on top of chronic use

• Immediate interventions:

  • Correct electrolyte abnormalities:
    • Potassium supplementation for hypokalemia (K+ 3.3)
    • Magnesium supplementation for hypomagnesemia (Mg 1.5)
  • Monitor for signs of hepatic encephalopathy given elevated anion gap (19)
  • Address severe thrombocytopenia (platelet count 27,000)

Management of Thrombocytopenia

• Thrombocytopenia management 1, 2, 3:
  • Avoid invasive procedures while platelet count is <50,000/μL
  • Platelet transfusion may be indicated if active bleeding occurs or urgent procedures are needed
  • Thrombocytopenia will likely improve with alcohol abstinence after 2-5 days 4, 5
  • Monitor platelet count daily during hospitalization

Alcoholic Hepatitis Treatment

• Nutritional support 1:

  • Provide high-protein diet (1-1.5 g/kg/day) and adequate calories (30-40 kcal/kg/day)
  • Supplement with B vitamins (particularly thiamine) and folic acid
  • Consider enteral nutrition if unable to meet requirements orally

• Medication management:

  • If MDF >32 or MELD >20 without contraindications, consider methylprednisolone 32 mg daily 1
  • If contraindications to steroids exist, consider pentoxifylline 400 mg three times daily 1
  • Assess response to therapy using Lille model after 7 days of treatment

• Infection surveillance 1:

  • Obtain blood, urine, and ascitic fluid (if present) cultures
  • Monitor for signs of infection even in absence of fever
  • Prophylactic antibiotics are not routinely recommended unless specific indications exist

Management of Complications

• Monitor for and treat:
  • Hepatic encephalopathy: Lactulose therapy if signs develop
  • Ascites: Sodium restriction (2000 mg/day) and diuretic therapy if needed
  • Acute kidney injury: Avoid nephrotoxic drugs including NSAIDs and certain diuretics 1
  • Alcohol withdrawal: Implement CIWA protocol with benzodiazepines as needed

Long-term Management

• Alcohol cessation counseling 6:

  • Complete abstinence is the cornerstone of treatment
  • Arrange addiction medicine consultation for pharmacotherapy options (naltrexone, acamprosate, etc.)
  • Provide resources for outpatient support (AA, counseling)

• Follow-up care:

  • Monitor liver function tests and platelet count weekly until normalized
  • Hepatology referral for ongoing management of liver disease
  • Screening for varices with upper endoscopy once stabilized
  • Surveillance for hepatocellular carcinoma with ultrasound every 6 months 6

Prognosis and Transplant Consideration

• If patient has severe alcoholic hepatitis with poor prognostic indicators (MELD >26) and demonstrates good insight and social support, consider early liver transplant evaluation 1
• Continued alcohol consumption is the most important factor increasing risk of complications and death 6

Pitfalls to Avoid

• Do not administer iodinated contrast for imaging studies due to risk of acute kidney injury 1
• Avoid unnecessary invasive procedures while platelet count is severely decreased
• Do not withhold nutritional support; malnutrition worsens outcomes
• Avoid infliximab in patients with alcoholic hepatitis and elevated liver enzymes 1
• Do not discharge prematurely; patients require close monitoring for complications