What is the management algorithm for alcoholic hepatitis?

Management Algorithm for Alcoholic Hepatitis

All patients with suspected alcoholic hepatitis require immediate assessment of disease severity using validated scoring systems, followed by universal interventions (abstinence, nutrition, infection screening) and severity-based pharmacologic treatment with corticosteroids for severe disease. 1, 2

Step 1: Establish Diagnosis

Diagnostic Criteria:

• Onset of jaundice within 8 weeks of last drinking episode 3
• Heavy alcohol consumption (>40 g/day or 3 standard drinks) for >6 months, typically years 3
• Serum bilirubin >3.0 mg/dL 3
• Serum AST >50 IU/L but <400 IU/L 3
• AST/ALT ratio >1.5 3
• Liver biopsy (showing macrovesicular steatosis, neutrophil infiltration, ballooning degeneration, megamitochondria, Mallory-Denk bodies) is helpful but not required for clinical diagnosis 3

Step 2: Assess Disease Severity

Calculate severity scores immediately upon diagnosis:

• Maddrey Discriminant Function (MDF): MDF ≥32 indicates severe disease with high 28-day mortality 3, 1, 2
• MELD score: >20 predicts high 90-day mortality and indicates severe disease 3, 1, 2
• Glasgow Alcoholic Hepatitis Score: ≥9 predicts high 28-day mortality 3, 1
• ABIC score: Category C predicts high 28- and 90-day mortality 3, 1

Critical point: Laboratory parameters are more reliable than clinical symptoms or imaging for predicting severity 3

Step 3: Universal Interventions (All Patients)

A. Immediate Infection Screening

• Obtain cultures of blood, urine, and ascites (if present) regardless of fever presence 3, 1, 2
• Infections are common and associated with high mortality, particularly in steroid non-responders 2

B. Enforce Complete Alcohol Abstinence

• Abstinence is the cornerstone of treatment and essential for survival 3, 1, 2
• Without abstinence, 90-day mortality is 40-50% 3
• Consider naltrexone or acamprosate combined with counseling to reduce relapse risk 2

C. Aggressive Nutritional Support

• Provide 30-40 kcal/kg/day and 1.2-1.5 g protein/kg/day 1, 2
• If unable to eat due to anorexia or altered mental status, use enteral feeding via feeding tube 3
• Enteral nutrition improves survival regardless of steroid treatment 2
• Parenteral nutrition alone is inadequate 3

D. Avoid Nephrotoxic Agents

• Do not use diuretics - acute kidney injury represents early multi-organ failure 1, 2
• Use caution with iodinated contrast for imaging as it increases acute kidney injury risk 3, 1

Step 4: Severity-Based Pharmacologic Treatment

For Severe Disease (MDF ≥32 OR MELD >20 OR Hepatic Encephalopathy)

Initiate Corticosteroids if no contraindications:

• Prednisolone 40 mg daily for 28 days (followed by discontinuation or 2-week taper) 1, 2
• Timing: Take up to 6-7 days from admission to systematically evaluate for contraindications before initiating steroids 4
• Corticosteroids improve 28-day survival by reducing pro-inflammatory cytokines including TNF-α 2

Absolute Contraindications to Steroids:

• Active gastrointestinal bleeding 2
• Renal failure 2
• Acute pancreatitis 2
• Uncontrolled infection 2

For Mild-Moderate Disease (MDF <32 AND MELD <20)

• Supportive care with abstinence and nutritional support alone 5, 6
• These patients generally improve with abstinence and adequate nutrition 6

Step 5: Monitor Treatment Response at Day 7

Assess response using Lille Model or Early Change in Bilirubin Level (ECBL):

• Lille score <0.45: Good response with 85% 6-month survival - continue steroids 1
• Lille score >0.45: Poor response with 25% 6-month survival - discontinue steroids immediately 1

Critical caveat: Discontinuing steroids in non-responders is essential as infections occur more frequently in steroid non-responders 2

Step 6: Complete Steroid Course and Taper

For responders at day 7:

• Complete 28 days of prednisolone 40 mg daily 1, 2
• Use a 2-week taper (lowest possible steroid exposure) 4
• Most infections occur within the first month of treatment, requiring vigilant monitoring 4

Step 7: Ongoing Monitoring and Follow-up

During hospitalization:

• Monitor continuously for new infections, which can develop after initial diagnosis 1, 2
• Watch for gastrointestinal bleeding, renal impairment, and hepatic encephalopathy 4

Post-discharge:

• Close outpatient follow-up after steroid taper 4
• Long-term prognosis depends on maintaining abstinence 3
• Consider liver transplantation evaluation for patients who achieve stable abstinence if liver function fails to recover 5, 7

Critical Pitfalls to Avoid

• Do not delay infection screening - obtain cultures immediately regardless of fever 3, 1
• Do not continue steroids in non-responders - reassess at day 7 and stop if Lille score >0.45 1, 2
• Do not use diuretics - they worsen acute kidney injury and multi-organ failure 1, 2
• Do not rely on parenteral nutrition alone - enteral feeding is essential 3
• Do not rush steroid initiation - take up to a week to exclude contraindications 4