Management of Alcoholic Hepatitis
The cornerstone of treatment for alcoholic hepatitis is complete abstinence from alcohol, which should be immediately implemented along with comprehensive evaluation of disease severity using validated scoring systems to guide appropriate interventions. 1
Assessment and Diagnosis
- Evaluate severity using validated prognostic models: Maddrey Discriminant Function (MDF), MELD score, Glasgow Alcoholic Hepatitis Score (GAHS), or ABIC score 1
- MDF ≥32 or MELD >20 indicates severe alcoholic hepatitis with high 28-day mortality (30-50%) 1
- Obtain blood, urine, and ascites (if present) cultures to rule out infection regardless of fever presence 1
- Consider liver imaging while avoiding iodinated contrast due to increased risk of acute kidney injury 1
- Liver biopsy via transjugular route may be considered for definitive diagnosis in unclear cases, especially when considering corticosteroid treatment 1
Initial Management
- Hospitalize patients with severe alcoholic hepatitis or those with inadequate social/medical support to ensure abstinence, restore nutrition, and exclude infections 1
- Implement alcohol abstinence counseling and support immediately 1
- Provide nutritional support with 1-1.5g protein and 30-40 kcal/kg body weight daily 1
- Consider enteral feeding via nasogastric tube if patient cannot eat due to anorexia or altered mental status 1
- Avoid nephrotoxic drugs including diuretics, as acute kidney injury is an early manifestation of multi-organ failure 1
- Monitor for systemic inflammatory response syndrome (SIRS), which increases risk of multi-organ failure 1
Pharmacological Management
- For severe alcoholic hepatitis (MDF ≥32 or MELD >20) without contraindications, administer methylprednisolone 32 mg daily 1
- For patients with contraindications to corticosteroids (hepatitis B infection, tuberculosis, serious infections), consider pentoxifylline 400 mg three times daily with meals, though efficacy data are conflicting 1
- Consider combination of N-acetylcysteine with corticosteroids, which has shown short-term survival benefit at 1 and 3 months in one study 1
- Assess response to corticosteroid therapy after 7 days using the Lille model; scores ≥0.45 indicate poor response with high 6-month mortality 1
Liver Transplantation Consideration
- Refer patients with severe alcoholic hepatitis (particularly MELD >26) with good insight into their alcohol use disorder and strong social support for liver transplantation evaluation 1
- The 90-day mortality rate is very high in these patients without transplantation 1
Monitoring and Follow-up
- Combine Lille and MELD scores for optimal evaluation of short and medium-term mortality risk 1
- Monitor for infections during treatment, especially in patients on corticosteroids 1
- Provide B vitamins and folic acid supplementation 1
- Focus on long-term abstinence as it significantly improves 5-year survival (80% with abstinence vs. 50% with relapse) 1
Mild to Moderate Alcoholic Hepatitis
- For patients with mild to moderate disease (MELD <20, MDF <32), focus on abstinence counseling and nutritional support 1
- Prescribe high protein diet supplemented with B vitamins and folic acid 1
- Even in these "less severe" cases, recognize that mortality remains significant (10% at 6 months, 20% at 1 year) 1
Common Pitfalls to Avoid
- Do not delay assessment of disease severity - early stratification is crucial for timely intervention 1
- Do not overlook infections which can precipitate multi-organ failure; perform thorough infection screening 1
- Avoid iodinated contrast agents which increase risk of acute kidney injury 1
- Do not rely on parenteral nutrition alone as it is inadequate for recovery 1
- Remember that most patients with alcoholic hepatitis already have underlying cirrhosis at diagnosis 1