What is the management of haematemesis in a patient with alcoholic hepatitis?

Management of Haematemesis in Alcoholic Hepatitis

Haematemesis in a patient with alcoholic hepatitis requires immediate hospitalization with urgent upper endoscopy to identify and treat the bleeding source (typically variceal or erosive gastritis), while simultaneously addressing infection risk, maintaining hemodynamic stability, avoiding nephrotoxic agents, and ensuring aggressive nutritional support—all within the framework that most patients with alcoholic hepatitis already have underlying cirrhosis with portal hypertension. 1

Immediate Assessment and Stabilization

Hospitalization and Infection Screening

• All patients with alcoholic hepatitis presenting with haematemesis must be hospitalized immediately to manage the acute bleeding, encourage alcohol abstinence, and exclude serious bacterial infections that commonly precipitate decompensation. 1
• Obtain cultures of blood, urine, and ascites (if present) immediately upon admission, regardless of fever presence, as infections are both precipitating events and factors leading to poor outcomes. 1
• Fever and elevated white blood cell counts are unreliable indicators of infection in alcoholic hepatitis; maintain high clinical suspicion for bacterial and fungal infections. 1
• The presence of systemic inflammatory response syndrome (SIRS) on admission significantly increases risk of multi-organ failure (MOF), which carries extremely high mortality. 1

Hemodynamic Management and Nephrotoxic Drug Avoidance

• Avoid or use diuretics sparingly, as acute kidney injury (AKI) is an early manifestation of MOF and can develop from infection, intravascular volume depletion, or nephrotoxic drugs. 1
• Do not administer iodinated contrast dye for imaging, as this significantly increases AKI risk in patients with cirrhosis, similar to risks seen in diabetes and heart failure. 1
• Maintain careful fluid balance to prevent both volume depletion (which precipitates AKI) and volume overload. 1

Endoscopic Evaluation and Bleeding Management

Source Identification

• Perform urgent upper endoscopy to identify the bleeding source, recognizing that the majority of patients with alcoholic hepatitis have underlying cirrhosis at diagnosis. 1
• Common bleeding sources include esophageal or gastric varices (from portal hypertension) and erosive gastritis from alcohol-induced mucosal damage. 2

Endoscopic Therapy

• Endoscopic therapy is necessary for active bleeding from varices or other identified sources. 2
• If endoscopy is not effective in controlling bleeding, consider angiographic embolization techniques as an alternative intervention. 2

Gastritis-Specific Management

• If alcoholic gastritis is the bleeding source, initiate proton pump inhibitors (PPIs) to reduce gastric acid secretion and promote mucosal healing. 2
• Complete alcohol abstinence is the most important treatment for alcoholic gastritis, as continued consumption perpetuates mucosal damage and inflammation. 2

Severity Assessment and Prognosis

Calculate Prognostic Scores

• Assess severity using validated scoring systems: Maddrey Discriminant Function (MDF), MELD score, ABIC score, or Glasgow Alcoholic Hepatitis Score. 1
• MDF > 32 predicts high 28-day mortality; MELD > 20 predicts high 90-day mortality. 1
• These laboratory-based parameters are more reliable predictors of severe disease than clinical symptoms, signs, or imaging criteria. 1
• Without treatment and abstinence, 90-day mortality is 40-50%. 1

Nutritional Support (Critical Component)

Aggressive Nutritional Intervention

• Provide 35-40 kcal/kg/day with protein intake of 1.2-1.5 g/kg/day (increase to 1.5 g/kg/day in severely ill patients). 2
• Nutritional intake is a major determinant of mortality; patients consuming < 21.5 kcal/kg/day have significantly lower survival. 1
• If the patient cannot eat due to anorexia or altered mental status, consider enteral feeding via nasogastric tube—parenteral nutrition alone is inadequate. 1
• Normal-to-high protein diets are safe and do not increase encephalopathy risk in alcoholic hepatitis. 1

Micronutrient Supplementation

• Provide comprehensive vitamin and mineral supplementation: vitamin A, thiamine, vitamin B12, folic acid, pyridoxine, vitamin D, and zinc. 2
• B-complex vitamins are especially critical in alcohol users due to common deficiencies. 2

Pharmacologic Treatment Considerations

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

• For patients without contraindications (active infection, hepatitis B, tuberculosis, gastrointestinal bleeding), consider methylprednisolone 32 mg daily. 1
• However, glucocorticoids only modestly improve 28-day mortality and provide no benefit at 90 days or 1 year, largely due to increased infection risk. 1
• The combination of prednisolone plus N-acetylcysteine (NAC) intravenously over the first 5 days showed the most significant improvement in 1-month mortality (8% vs 24% with prednisolone alone) and reduced infections (19% vs 42%). 1

Active Bleeding as Contraindication

• Active gastrointestinal bleeding is a relative contraindication to glucocorticoid therapy due to increased infection risk and impaired immune response. 1
• In the setting of acute haematemesis, prioritize hemostasis, infection screening, and supportive care before considering immunosuppressive therapy. 1
• Pentoxifylline may be considered as an alternative, though evidence is mixed. 1

Monitoring and Response Assessment

Early Response Evaluation

• Use the Lille score at day 7 to predict treatment response if glucocorticoids are initiated. 1
• Discontinue glucocorticoids in patients who fail to improve based on Lille criteria. 1

Transplant Consideration

• Patients with MELD > 26 should be considered for liver transplantation, which may be life-saving. 1
• Outcomes of liver transplantation in alcoholic hepatitis are similar to other patients with comparable MELD scores. 1

Alcohol Cessation and Long-Term Management

Immediate Abstinence

• Abstinence from alcohol is the absolute cornerstone of treatment and essential for long-term survival. 1
• Patients who return to heavy drinking have far worse prognosis than those who remain abstinent. 1

Structured Interventions

• Implement brief alcohol intervention during hospitalization, which reduces future alcohol consumption by approximately 41 g/week. 2
• Arrange extended alcohol counseling after discharge to maintain abstinence. 2
• Be vigilant for signs of alcohol withdrawal, which may require specific management protocols. 2

Critical Pitfalls to Avoid

• Never assume absence of infection based on lack of fever or normal white blood cell count—these are unreliable in alcoholic hepatitis. 1
• Avoid all nephrotoxic medications and contrast dye, as AKI rapidly progresses to MOF with extremely high mortality. 1
• Do not delay nutritional support—malnutrition impairs recovery and is a major mortality determinant. 1
• Recognize that alcoholic hepatitis often coexists with cirrhosis and portal hypertension, making variceal bleeding more likely than simple gastritis. 1, 2
• Do not initiate glucocorticoids during active bleeding without first achieving hemostasis and excluding infection. 1