What is the management of alcoholic hepatitis?

Management of Alcoholic Hepatitis

The cornerstone of alcoholic hepatitis management is complete abstinence from alcohol, with severity-based treatment including corticosteroids for severe cases (MDF >32 or MELD >20), nutritional support, infection screening, and consideration of liver transplantation for selected patients with MELD >26. 1

Diagnosis and Severity Assessment

• Alcoholic hepatitis (AH) is diagnosed based on clinical presentation of jaundice within 8 weeks of drinking, history of heavy alcohol consumption (>40g/day), elevated bilirubin (>3.0 mg/dL), AST >50 IU/L but <400 IU/L, and AST/ALT ratio >1.5 1
• Severity assessment should be performed using validated scoring systems:
  • Maddrey discriminant function (MDF) >32 predicts high 28-day mortality 1
  • MELD score >20 predicts high 90-day mortality 1
  • Glasgow alcoholic hepatitis score of 9 predicts high 28-day mortality 1
  • ABIC score category C predicts high 28-day and 90-day mortality 1

Initial Management for All Patients

• Complete abstinence from alcohol is essential and significantly improves survival 1, 2
• Screen for infections with cultures of blood, urine, and ascites (if present), regardless of fever presence 1, 2
• Perform liver imaging as part of evaluation, but use caution with iodinated contrast agents due to risk of acute kidney injury 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

Nutritional Support

• Provide high-protein, high-calorie diet with 1-1.5g protein and 30-40 kcal/kg body weight daily 1
• Consider enteral feeding via feeding tube if patient is unable to eat due to anorexia or altered mental status 1, 3
• Supplement with B vitamins and folic acid 1, 2
• Avoid parenteral nutrition alone as it is inadequate 1

Treatment Based on Disease Severity

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

• Abstinence counseling and supportive care 1, 2
• High-protein diet supplemented with B vitamins and folic acid 1, 2
• Regular monitoring for disease progression 2

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

• Methylprednisolone 32 mg daily for patients without contraindications to glucocorticoids 1
  • Contraindications include hepatitis B viral infection, tuberculosis, or other serious infectious diseases 1
  • Note that benefits are modest and limited to short-term (<28 days) mortality 1
  • Assess response after 7 days using Lille model; discontinue if no improvement 1
• For patients with contraindications to glucocorticoids, pentoxifylline 400 mg three times daily with meals may be considered, though efficacy data are conflicting 1, 4
• N-acetylcysteine added to corticosteroids may decrease hepatorenal syndrome and infection incidence but does not significantly affect 6-month mortality 3

Critical Alcoholic Hepatitis (MELD >26)

• Consider referral for liver transplantation evaluation in highly selected patients with:
  • Good insight into their alcohol use disorder 1
  • Strong social support 1
  • No response to medical therapy 5

Management of Complications

• Alcohol withdrawal syndrome: Evaluate and treat promptly using standardized assessment tools 1, 2
• Infections: Early recognition and treatment with appropriate antibiotics is crucial 1, 5
• Nutritional deficiencies: Supplement vitamins and minerals, particularly vitamin A, thiamine, B12, folic acid, pyridoxine, vitamin D, and zinc 2

Common Pitfalls and Caveats

• Don't underestimate the importance of abstinence - it is the most critical intervention for both short and long-term survival 1
• Don't delay nutritional therapy - malnutrition significantly worsens outcomes 1, 3
• Don't miss infections - they are common and can precipitate multi-organ failure 1
• Don't continue corticosteroids if no response after 7 days (per Lille model) as this increases risk without benefit 1
• Don't assume mild alcoholic hepatitis will always recover with abstinence alone - close monitoring is still required 2

Long-term Considerations

• The 1-year mortality rate remains high at 56% even with treatment, highlighting the need for continued abstinence 1
• Consider medications to support abstinence such as baclofen or acamprosate 2
• Regular follow-up to monitor for disease progression and development of cirrhosis 2, 5