Treatment of Alcoholic Hepatitis and Assessment of Hepatic Encephalopathy Resolution
For alcoholic hepatitis treatment, complete abstinence from alcohol is the most important intervention, followed by nutritional support and corticosteroids for severe cases, while resolution of hepatic encephalopathy is determined by improvement in mental status, reduction in blood ammonia levels, and normalization of EEG patterns. 1, 2
Assessment of Alcoholic Hepatitis Severity
- Evaluate disease severity using validated scoring systems including Maddrey discriminant function (MDF) >32, MELD score >20, Glasgow alcoholic hepatitis score of 9, or ABIC score category C to guide treatment decisions 2
- Laboratory parameters are more reliable predictors of severe disease than clinical symptoms, signs, or imaging criteria 1
- Screen all patients for infections regardless of fever presence, with cultures of blood, urine, and ascites (if present) 2
Treatment Approach for Alcoholic Hepatitis
First-Line Interventions
- Complete alcohol abstinence is the most important treatment for alcoholic hepatitis, as continued alcohol use leads to disease progression and worsens outcomes 1, 2
- Provide active nutritional support with protein intake of 1.2-1.5 g/kg/day and caloric intake of 35-40 kcal/day; if three meals per day are inadequate, additional meals in early morning and late night are recommended 1
- Supplement vitamins and minerals (vitamin A, thiamine, vitamin B12, folic acid, pyridoxine, vitamin D, and zinc) along with nutritional therapy 1
Treatment Based on Disease Severity
- For severe alcoholic hepatitis (MDF ≥32, MELD >20), administer corticosteroids (prednisolone 40 mg daily for 28 days) 1, 2
- Assess response to steroids at day 7 using the Lille model or Early Change in Bilirubin Level (ECBL) 1, 2
- Lille score <0.45 indicates good response (85% 6-month survival)
- Lille score >0.45 indicates poor response (25% 6-month survival)
- Consider discontinuing steroids in null responders based on ECBL or Lille model to reduce infection risk 1
- Steroids are contraindicated in patients with gastrointestinal bleeding, renal failure, pancreatitis, or uncontrolled infection 1
Management of Hepatic Encephalopathy
Assessment of Hepatic Encephalopathy Resolution
- Resolution of hepatic encephalopathy is determined by: 3
- Improvement in mental state
- Reduction in blood ammonia levels by 25-50%
- Improvement in EEG patterns
Treatment of Hepatic Encephalopathy
- Lactulose is indicated for prevention and treatment of portal-systemic encephalopathy, including stages of hepatic pre-coma and coma 3
- Rifaximin (550 mg twice daily) is indicated for reduction in risk of overt hepatic encephalopathy recurrence in adults 4
- In clinical trials of rifaximin for hepatic encephalopathy, 91% of patients were using lactulose concomitantly 4
- Avoid nephrotoxic drugs, including diuretics, as acute kidney injury is an early manifestation of multi-organ failure 2
Special Considerations and Monitoring
- Monitor for infections, which can develop after initial diagnosis and are associated with high mortality 2
- Use caution with iodinated contrast agents for imaging, as they increase the risk of acute kidney injury 2
- Consider liver transplantation in patients with MELD score >26 who fail to improve with medical therapy 1
- Long-term prognosis is improved with abstinence, but complications (ascites, gastrointestinal bleeding) may still occur 5
Common Pitfalls and Caveats
- Steatosis is reversible upon withdrawal of alcohol, but alcoholic hepatitis can persist even with abstinence and may progress to cirrhosis 5
- Rifaximin has not been studied in patients with MELD scores >25, and only 8.6% of patients in controlled trials had MELD scores over 19 4
- There is increased systemic exposure to rifaximin in patients with more severe hepatic dysfunction 4
- Clostridium difficile-associated diarrhea has been reported with use of rifaximin and should be considered in patients who develop diarrhea following antibiotic use 4