What is the management approach for a patient with alcoholic hepatitis?

Management of Alcoholic Hepatitis

Immediate Assessment and Hospitalization

Patients with severe alcoholic hepatitis (MDF ≥32 or MELD >20) must be hospitalized immediately to ensure abstinence, restore nutrition, and exclude infections, as untreated severe disease carries 30-50% mortality at 28 days. 1, 2

• Assess disease severity using validated scoring systems: Maddrey Discriminant Function (MDF), MELD score, Glasgow Alcoholic Hepatitis Score, or ABIC score 1, 2
• MDF ≥32 or MELD >20 defines severe alcoholic hepatitis requiring aggressive intervention 1, 2
• Obtain blood, urine, and ascites cultures (if present) immediately regardless of fever, as infections are common precipitants of decompensation and multi-organ failure 1, 2
• Perform liver imaging but avoid iodinated contrast agents due to significantly increased risk of acute kidney injury 1, 2
• Consider transjugular liver biopsy for definitive diagnosis in unclear cases, especially before initiating corticosteroids 2

Alcohol Abstinence - The Foundation of All Treatment

Complete and permanent alcohol abstinence is the single most important intervention and determines long-term survival regardless of pharmacologic therapy. 1, 2, 3

• Implement immediate abstinence counseling and psychosocial support during hospitalization 1
• Consider pharmacologic aids: baclofen or acamprosate can be used to maintain abstinence 1
• Long-term survival is 80% with maintained abstinence versus 50% with alcohol relapse, even in treatment responders 2, 3

Nutritional Support - Critical for Recovery

Provide aggressive nutritional support with 1-1.5 g protein/kg/day and 30-40 kcal/kg/day, as malnutrition is a major determinant of mortality. 1, 2

• If oral intake is inadequate due to anorexia or altered mental status, place a feeding tube for enteral nutrition 1, 2
• Parenteral nutrition alone is inadequate and should not be used as sole nutritional support 1, 2
• Supplement with B vitamins (thiamine, B12, pyridoxine), folic acid, vitamin A, vitamin D, and zinc 1
• Consider multiple small meals throughout the day if three meals are insufficient 1

Pharmacologic Management for Severe Disease

For severe alcoholic hepatitis (MDF ≥32 or MELD >20) without contraindications, administer methylprednisolone 32 mg daily or prednisolone 40 mg daily for 28 days. 1, 2, 3

Corticosteroid Therapy Algorithm:

• Contraindications to steroids include: active bacterial infection, hepatitis B infection, tuberculosis, or active gastrointestinal bleeding 1, 2
• Assess response at day 7 using the Lille score 2, 3
• Lille score ≥0.45 indicates non-response with high 6-month mortality; discontinue steroids in these patients 2, 3
• Corticosteroids improve 28-day survival modestly but provide no benefit beyond 28 days 1, 4, 5

Alternative and Adjunctive Therapies:

• Consider N-acetylcysteine combined with corticosteroids, which showed improved 1-month survival (8% vs 24% mortality) and reduced infections (19% vs 42%) in one high-quality study 2, 6
• Pentoxifylline 400 mg three times daily may be used if corticosteroids are contraindicated, though data on efficacy are conflicting 1, 5

Prevention of Multi-Organ Failure

Avoid nephrotoxic drugs including diuretics, as acute kidney injury is an early manifestation of multi-organ failure which carries extremely high mortality. 1, 2

• Monitor closely for systemic inflammatory response syndrome (SIRS), which predicts multi-organ failure 1, 2
• Maintain careful fluid balance to prevent both volume depletion and overload 2
• Perform extensive bacteriological examination if any signs of infection develop during treatment 2, 3

Liver Transplantation for Refractory Cases

Patients with severe alcoholic hepatitis (particularly MELD >26) who fail medical therapy should be referred for liver transplantation evaluation if they have good insight into their alcohol use disorder and strong social support. 1, 2

• Early liver transplantation in carefully selected patients with first episode of severe alcoholic hepatitis yields 6-month survival rates of 77-100% 7
• The traditional 6-month abstinence requirement cannot be met by patients with severe disease who are steroid non-responders 4, 7
• Transplantation outcomes are comparable to other indications when patient selection is rigorous 7

Management of Mild to Moderate Disease

For patients with MDF <32 and MELD <20, focus on abstinence counseling and nutritional support without corticosteroids. 1, 2

• Prescribe high-protein diet supplemented with B vitamins and folic acid 1, 2
• Provide intensive alcohol cessation counseling 1, 2
• Recognize that even "mild" disease carries 10% mortality at 6 months and 20% at 1 year 2

Monitoring and Prognostication

Combine Lille and MELD scores for optimal prediction of short and medium-term mortality risk. 2, 3

• Reassess severity throughout hospitalization as clinical status can deteriorate rapidly 1, 2
• Monitor for development of hepatic encephalopathy, gastrointestinal bleeding, renal failure, and infections 7
• Most patients with alcoholic hepatitis already have underlying cirrhosis at diagnosis 2

Critical Pitfalls to Avoid

• Do not delay severity assessment - early stratification determines appropriate intervention 2
• Do not overlook infections - they precipitate multi-organ failure and are often present without fever or leukocytosis 1, 2
• Do not continue corticosteroids beyond 7 days in non-responders (Lille ≥0.45) as they only increase infection risk without benefit 2, 3
• Do not rely on fever or elevated white blood cell count to diagnose infection in these patients 2