What is considered decompensated alcohol hepatitis?

Decompensated Alcoholic Hepatitis

Alcoholic hepatitis itself represents acute decompensation of alcoholic liver disease, characterized by the rapid onset of jaundice—which is the hallmark clinical sign of decompensation in this condition. 1

Core Definition of Decompensation in Alcoholic Hepatitis

The term "decompensated" in the context of alcoholic hepatitis refers to the acute deterioration with specific clinical and laboratory features:

Clinical Manifestations

• Rapid onset of jaundice (within 60 days of heavy alcohol consumption) is the defining feature of decompensation 1
• Malaise, anorexia, and tender hepatomegaly accompany the jaundice 1
• Features of systemic inflammatory response syndrome (SIRS): tachycardia, tachypnea, fever, and leukocytosis 1

Laboratory Criteria for Diagnosis

• Serum bilirubin >3.0 mg/dL (the threshold defining clinically significant decompensation) 1
• Serum AST 50-400 IU/L 1
• AST:ALT ratio >1.5 1
• Heavy alcohol consumption (>40-50 g/day) for minimum 6 months 1

Severity Assessment of Decompensation

The degree of decompensation is quantified using validated scoring systems that predict mortality risk:

Severe Decompensation Defined By:

• Maddrey Discriminant Function (MDF) ≥32 predicts >50% mortality at 28 days without treatment 1
• MELD score >20 predicts high 90-day mortality 1
• ABIC score category C predicts high 28- and 90-day mortality 1
• Glasgow alcoholic hepatitis score ≥9 predicts high 28-day mortality 1

Clinical Complications Indicating Decompensation

Patients with decompensated alcoholic hepatitis are at extremely high risk for:

• Multiorgan failure (MOF) syndrome, particularly when SIRS is present 1
• Acute kidney injury (AKI), which is an early manifestation of MOF 1
• Bacterial and fungal infections due to impaired neutrophil function 1
• Hepatic encephalopathy (associated with highest mortality among complications) 1
• Variceal bleeding 1
• Ascites 1

Critical Context: Underlying Cirrhosis

The majority of patients with alcoholic hepatitis already have underlying cirrhosis at the time of diagnosis 1. This means alcoholic hepatitis typically represents acute-on-chronic decompensation rather than isolated acute liver injury. The presence of cirrhosis with superimposed alcoholic hepatitis carries particularly poor prognosis, with 40-50% mortality within 90 days without treatment and abstinence 1.

Distinguishing Decompensated from Mild Disease

Patients with mild alcoholic hepatitis (MDF <32, MELD <20) may have jaundice but lack the severe systemic manifestations and have significantly better prognosis 2. The distinction is critical because:

• Severe disease requires consideration for corticosteroid therapy 1
• Severe disease may warrant early liver transplantation evaluation in non-responders 3, 4
• Mild disease is managed primarily with supportive care and abstinence 2

Common Pitfall

Do not confuse "decompensated alcoholic cirrhosis" with "decompensated alcoholic hepatitis." Alcoholic hepatitis is itself a form of acute decompensation of alcoholic liver disease 1. When clinicians refer to "decompensated" in this context, they are typically referring to the severity of the alcoholic hepatitis episode (severe vs. mild) rather than a separate state of decompensation 1.