Is alcoholic hepatitis curable?

Alcoholic Hepatitis: Curability and Management

Alcoholic hepatitis is not completely curable, but it is potentially reversible in its early stages with complete abstinence from alcohol, though some cases may still progress to cirrhosis despite abstinence. 1, 2

Understanding Alcoholic Hepatitis and Its Progression

Alcoholic hepatitis is part of the spectrum of alcoholic liver disease, which includes:

1. Alcoholic fatty liver (steatosis)

   • Most common form (80-90% of heavy drinkers)
   • Fully reversible with abstinence
   • Risk of progression: 30-37% may progress to cirrhosis with continued drinking 1

2. Alcoholic hepatitis (steatohepatitis)

   • Characterized by inflammation and often accompanied by fatty liver
   • More than 50% of symptomatic patients have concomitant cirrhosis 1
   • Severe cases have 40% one-month mortality 1

3. Alcoholic cirrhosis

   • End-stage, irreversible liver damage
   • 15-30% lifetime risk with long-term excessive drinking 1

Reversibility and Prognosis

The potential for recovery depends on several factors:

• Disease stage: Early alcoholic hepatitis without significant fibrosis has better potential for reversal 1, 2
• Abstinence: Complete abstinence from alcohol is essential but not always sufficient 1
  • Even with abstinence, 5-15% of patients may still develop fibrosis or cirrhosis 1
  • In compensated alcoholic cirrhosis, 5-year survival is 90% with abstinence vs <70% with continued drinking 1
  • In decompensated cirrhosis, 5-year survival is 60% with abstinence vs 30% with continued drinking 1

Assessment and Treatment Approach

Severity Assessment

Evaluate severity using validated scoring systems 3:

• Maddrey Discriminant Function (MDF)
• MELD score
• ABIC score
• Glasgow scoring system

Treatment Based on Severity

Mild to Moderate Alcoholic Hepatitis (MDF <32, MELD <20)

• Complete abstinence from alcohol (cornerstone of treatment) 1, 3
• High protein diet (1.2-1.5 g/kg/day) 3
• B vitamins and folic acid supplementation 3
• Abstinence counseling 1

Severe Alcoholic Hepatitis (MDF ≥32, MELD >20)

• Complete abstinence from alcohol 1, 3
• Corticosteroids: Prednisolone 40 mg daily or methylprednisolone 32 mg daily for 28 days (if no contraindications) 1, 3
  • Contraindications: hepatitis B infection, tuberculosis, serious infections, gastrointestinal bleeding, renal failure 3
  • Assess response at day 7 using Lille model (discontinue if Lille score ≥0.56) 3
• Alternative: Pentoxifylline 400 mg three times daily (if steroids contraindicated) 1, 3
• Nutritional support (35-40 kcal/kg/day) 3
• Avoid nephrotoxic drugs including diuretics 1, 3

End-Stage Disease or Non-responders

• Liver transplantation consideration for selected patients with MELD >26 who:
  • Have good insight into their alcohol use disorder
  • Have good social support
  • Fail to respond to medical therapy 1, 3

Important Caveats and Pitfalls

1. Progression despite abstinence: Even with complete abstinence, alcoholic hepatitis can persist and progress to cirrhosis in some patients 2

2. Infection risk: Closely monitor for infections, especially in patients on corticosteroids (13% infection rate vs 7% in controls) 3

3. Multi-organ failure: Presence of systemic inflammatory response syndrome (SIRS) increases risk of multi-organ failure, which carries very high mortality 1

4. Acute kidney injury: An early manifestation of multi-organ failure; avoid nephrotoxic medications 1

5. Cirrhosis development: Once cirrhosis develops, liver damage becomes irreversible, though abstinence still improves prognosis 2

6. Monitoring response: Failure to assess response to corticosteroids at day 7 may result in unnecessary treatment continuation in non-responders 3

7. Nutritional deficiencies: Inadequate nutritional support can worsen outcomes; ensure adequate caloric and protein intake 3