Definition of Alcoholic Hepatitis
Alcoholic hepatitis is a clinical syndrome characterized by the rapid onset of jaundice (within 60 days) in patients with heavy alcohol consumption (>50 g/day for ≥6 months), accompanied by serum bilirubin >3 mg/dL, elevated AST (50-400 U/L), AST:ALT ratio >1.5, and exclusion of other causes of hepatitis. 1
Clinical Presentation
Alcoholic hepatitis represents a serious form of acute decompensation of alcoholic liver disease that develops in heavy drinkers and manifests with: 1
- Rapid onset of jaundice (developing within 60 days of heavy drinking) 1
- Malaise and anorexia 1
- Tender hepatomegaly 1
- Features of systemic inflammatory response syndrome (SIRS) including tachycardia, tachypnea, fever, and leukocytosis 1
- Potential decompensation with ascites, encephalopathy, bacterial infection, and variceal bleeding 1
Diagnostic Criteria
The NIAAA Alcoholic Hepatitis Consortium established a working definition requiring all of the following elements: 1
Alcohol Consumption Requirements
- Heavy alcohol use for >6 months with <60 days of abstinence before jaundice onset 1
- Consumption threshold: >50 g/day (approximately 4 standard drinks) for men, >40 g/day (approximately 3 drinks) for women 1
Laboratory Criteria
- Serum bilirubin >3 mg/dL (>50 μmol/L) 1
- AST elevation 50-400 U/L (typically not exceeding 400 U/L, which helps distinguish from drug-induced liver injury or ischemic hepatitis) 1
- AST:ALT ratio >1.5 (ratios <1.5 occur in <2% of histologically proven cases) 1
- Exclusion of other causes including viral hepatitis, biliary obstruction, severe autoimmune liver disease, Wilson disease, and drug-induced liver injury 1
Diagnostic Classification System
The NIAAA consensus statement proposed three diagnostic categories to improve research interpretation: 1
- Definite alcoholic hepatitis: Diagnosis established by liver biopsy 1
- Probable alcoholic hepatitis: Clinical and laboratory features present without confounding problems 1
- Possible alcoholic hepatitis: Clinical features present but with confounding problems 1
Histologic Features
When liver biopsy is performed, characteristic findings include: 1
- Macrovesicular steatosis 1
- Ballooning degeneration of hepatocytes (steatohepatitis) 1
- Neutrophil infiltration 1
- Mallory-Denk bodies 1
- Intrahepatic cholestasis (bilirubinostasis) 1
- Chicken-wire fibrosis 1
- Megamitochondria 1
- Cirrhosis (present in the vast majority of severely ill patients) 1
Clinical Significance and Prognosis
Severe alcoholic hepatitis carries a high short-term mortality rate of 40-50% if untreated, making accurate diagnosis critical for guiding therapy. 1, 2 The condition is associated with: 1
- High risk of nutritional deficiency 1
- Infection (common and must be identified) 1
- Acute kidney injury (AKI) 1
- Development of multiorgan failure (MOF) syndrome 1
Important Diagnostic Caveats
Liver biopsy reveals that 10-20% of patients with a clinical diagnosis of alcoholic hepatitis may have other liver diseases or may not have histologic alcoholic steatohepatitis, underscoring the value of biopsy when feasible. 1 However, the diagnosis is primarily clinical in most cases, with biopsy reserved for uncertain situations or research purposes. 1
The distinction between alcoholic hepatitis and nonalcoholic steatohepatitis (NASH) can be challenging, as elevated BMI is a risk factor for both conditions; differentiation typically relies on the amount of alcohol consumed and the rapid onset of jaundice. 1