From the Guidelines
Leukocytosis in alcoholic hepatitis is a significant finding that requires careful evaluation to distinguish between infection and the inflammatory response of the liver disease itself, and empiric antibiotic therapy should be initiated if infection is suspected, especially with fever, hypotension, or other signs of systemic inflammatory response, as recommended by the most recent guidelines 1.
Significance of Leukocytosis
Leukocytosis, or elevated white blood cell count, is a common finding in patients with alcoholic hepatitis, and it can range from 12,000-25,000 cells/μL, predominantly with neutrophils. This elevation in white blood cell count can be due to the inflammatory response of the liver disease itself or due to an underlying infection.
Evaluation and Management
When encountering leukocytosis in alcoholic hepatitis, it is essential to obtain cultures (blood, urine, ascitic fluid if present) to rule out infection before assuming it's solely due to alcoholic hepatitis. Empiric antibiotic therapy with ceftriaxone 1-2g IV daily or piperacillin-tazobactam 3.375g IV every 6 hours should be initiated if infection is suspected, especially with fever, hypotension, or other signs of systemic inflammatory response. Discontinue antibiotics if cultures are negative after 48-72 hours and no other signs of infection persist.
Pathophysiology
The leukocytosis in alcoholic hepatitis occurs because damaged hepatocytes release inflammatory cytokines (IL-1, IL-6, TNF-alpha) that stimulate bone marrow to produce neutrophils. This sterile inflammation can mimic infection, making clinical judgment crucial. Monitor white blood cell counts daily, as persistent elevation despite appropriate therapy may indicate complications like spontaneous bacterial peritonitis or other occult infections.
Key Points
- Leukocytosis is common in alcoholic hepatitis and requires careful evaluation to distinguish between infection and the inflammatory response of the liver disease itself.
- Empiric antibiotic therapy should be initiated if infection is suspected, especially with fever, hypotension, or other signs of systemic inflammatory response.
- The Lille score and MELD score are recommended for evaluating short- and medium-term risk of death in patients with severe alcoholic hepatitis, as stated in the most recent guidelines 1.
- Long-term outcomes depend mainly on achieving abstinence, and addiction treatment must be systematically offered after an episode of alcoholic hepatitis, as recommended by the guidelines 1.
From the Research
Significance of Leukocytosis in Alcoholic Hepatitis
- Leukocytosis, or elevated white blood cell count, is a common finding in patients with alcoholic hepatitis 2.
- The presence of leukocytosis, along with other symptoms such as fever, jaundice, and encephalopathy, should prompt consideration of alcoholic hepatitis as a diagnosis 2.
- Severe leukocytosis, defined as a white blood cell count greater than 50,000/mm3, has been reported in cases of alcoholic hepatitis and may be associated with a poor prognosis 3.
- The exact mechanism of leukocytosis in alcoholic hepatitis is not fully understood, but it may be related to the release of colony-stimulating factors from damaged hepatic cells 3.
- In some cases, leukocytosis may be a response to infection, which is a common complication of alcoholic hepatitis 4, 5.
- Treatment of alcoholic hepatitis typically involves abstinence from alcohol, nutrition, and supportive care, with corticosteroids and other medications used in select cases 2, 6.
- Granulocyte colony-stimulating factor (G-CSF) has been shown to improve survival in patients with severe alcoholic hepatitis, possibly by reducing the risk of infection and promoting liver regeneration 6.
Clinical Implications
- Leukocytosis should be considered a marker of disease severity in alcoholic hepatitis, and its presence should prompt careful evaluation for infection and other complications 4, 5.
- Patients with severe leukocytosis and alcoholic hepatitis may require closer monitoring and more aggressive treatment, including antibiotics and supportive care 4, 5.
- Further research is needed to fully understand the mechanisms of leukocytosis in alcoholic hepatitis and to develop effective treatments for this condition 6, 3.