What is the best course of treatment for a patient with suspected alcoholic liver disease, presenting with hematemesis (vomiting blood), melena (pooping blood), jaundice, elevated bilirubin (hyperbilirubinemia), thrombocytopenia (low platelet count), coagulopathy (elevated INR), anemia (low hemoglobin), and normal hepatitis panel results?

Management of Alcoholic Liver Disease with Upper GI Bleeding

This patient requires immediate hospitalization with urgent upper endoscopy for variceal bleeding management, aggressive infection surveillance, calculation of severity scores (Maddrey DF and MELD), and consideration of corticosteroids if severe alcoholic hepatitis is confirmed and infection is excluded. 1

Immediate Diagnostic Assessment

Your patient's presentation—hematemesis, melena, jaundice, coagulopathy (INR 1.9), thrombocytopenia (platelets 96), anemia (Hgb 9), and hyperbilirubinemia (bilirubin 10.8)—is consistent with severe alcoholic hepatitis complicated by portal hypertension and variceal bleeding. 2

Calculate Severity Scores

Maddrey Discriminant Function (MDF): Calculate using the formula: 4.6 × (patient's PT - control PT) + serum bilirubin. An MDF ≥32 defines severe alcoholic hepatitis with high 28-day mortality and indicates potential need for corticosteroid therapy. 2, 1

MELD Score: Calculate immediately—a MELD >20 predicts high 90-day mortality and should trigger early transplant evaluation consideration. 2, 1

Critical Laboratory and Diagnostic Steps

• Diagnostic paracentesis: Perform immediately if any ascites is present to rule out spontaneous bacterial peritonitis (SBP), as infection is an absolute contraindication to corticosteroid therapy. 1

• Blood, urine, and ascitic fluid cultures: Obtain regardless of fever presence, as infection is common and must be excluded before considering corticosteroids. 1

• Upper endoscopy: Perform urgently (within 12 hours) to identify and treat variceal bleeding, which is the likely source given the portal hypertension stigmata (thrombocytopenia, coagulopathy). 2

Acute Bleeding Management

Do NOT attempt to "correct" the INR or platelet count prophylactically with FFP or platelet transfusions. The 2022 EASL guidelines explicitly state that correcting abnormal coagulation tests with blood products to prevent bleeding is not recommended and lacks evidence. 2 The elevated INR reflects synthetic dysfunction, not simply a bleeding risk, and FFP transfusion carries significant risks (volume overload, transfusion reactions) without proven benefit. 2

Variceal Bleeding Protocol

• Vasoactive drugs: Start octreotide or terlipressin immediately upon suspicion of variceal bleeding, before endoscopy. 1

• Endoscopic therapy: Band ligation is preferred for esophageal varices; sclerotherapy or cyanoacrylate for gastric varices. 1

• Antibiotic prophylaxis: Administer third-generation cephalosporin (ceftriaxone 1g daily) immediately—this reduces bacterial infections and mortality in cirrhotic patients with GI bleeding. 1

Infection Surveillance and Management

Infection is the most critical factor to assess before any specific alcoholic hepatitis therapy. 1

• Start empiric antibiotics (third-generation cephalosporin) immediately if SBP is suspected (ascitic fluid PMN >250 cells/mm³). 1

• Monitor closely for sepsis, as infection precludes corticosteroid use and dramatically worsens prognosis. 2

• The normal lipase (100) and amylase (107) make acute pancreatitis less likely, but remain vigilant for this complication. 1

Nutritional and Supportive Care

Aggressive nutritional support is essential and improves outcomes. 1, 3

• Provide 1.0-1.5 g protein/kg/day and 30-40 kcal/kg/day, preferably via oral or enteral route. 1

• Thiamine supplementation: Administer immediately (100 mg IV/IM daily) to prevent Wernicke's encephalopathy—this is non-negotiable in all alcoholic patients. 1

• Consider multivitamin supplementation and folate replacement given chronic alcohol use. 1

Alcohol Withdrawal Management

Assess for and treat alcohol withdrawal syndrome aggressively with benzodiazepines (CIWA protocol), as withdrawal can complicate the clinical picture and worsen outcomes. 1

Corticosteroid Therapy Decision

If MDF ≥32 or hepatic encephalopathy is present, AND infection is definitively excluded, consider prednisolone 40 mg daily for 28 days. 2, 3

Contraindications to Corticosteroids

• Active infection (including SBP, pneumonia, UTI)
• Active GI bleeding (must be controlled first)
• Renal failure
• Pancreatitis 2, 3, 4

Important caveat: Only about 50% of patients with severe alcoholic hepatitis respond to corticosteroids, and the benefit is primarily short-term survival. 3, 5 Consider liver biopsy if diagnosis is uncertain and patient is a corticosteroid candidate, as only 70% of clinically suspected severe alcoholic hepatitis cases are confirmed histologically. 2

Avoid Common Pitfalls

Vitamin K administration is futile in this setting. Despite the elevated INR, vitamin K (even IV) does not improve INR in patients with alcoholic liver disease due to hepatocellular synthetic dysfunction, not vitamin K deficiency. 2, 6 The FDA label confirms that "repeated large doses of vitamin K are not warranted in liver disease if the response to initial use of the vitamin is unsatisfactory." 6

Avoid nephrotoxic drugs (NSAIDs, aminoglycosides, contrast) as hepatorenal syndrome risk is high with bilirubin of 10.8. 1

Disposition and Follow-up

• Hospital admission required: Severe alcoholic hepatitis with GI bleeding, coagulopathy, and high bilirubin mandates inpatient management. 1

• Early transplant evaluation: If MELD >26 or patient fails to respond to medical therapy within 7 days (Lille score >0.45), refer for liver transplantation evaluation. 1, 3

• Abstinence counseling: Initiate alcohol use disorder treatment immediately—abstinence is the single most effective intervention for long-term survival. 2, 3

The 90-day mortality for this presentation approaches 40-50%, making aggressive, protocol-driven management essential. 1