What is the management approach for a 43-year-old male with severe alcoholism (alcohol use disorder), presenting with jaundice, significantly elevated liver enzymes (alanine transaminase (ALT) elevation), hyperbilirubinemia (total bilirubin elevation), and abdominal distension likely due to ascites?

Management of Severe Alcoholic Hepatitis with Decompensation

Immediate Assessment and Hospitalization

This patient requires immediate hospitalization for severe alcoholic hepatitis with decompensation, as evidenced by jaundice, markedly elevated bilirubin (8.78 mg/dL), and ascites—all indicating high short-term mortality risk without aggressive intervention. 1

• Calculate severity scores immediately to stratify mortality risk and guide treatment decisions 1:

  • Maddrey Discriminant Function (MDF): Use formula 4.6 × (PT prolongation in seconds) + total bilirubin (mg/dL). MDF ≥32 defines severe disease with 40-50% mortality at 90 days without treatment 1
  • MELD score: MELD >20 predicts high 90-day mortality and should trigger consideration of corticosteroid therapy 1
  • You need INR/PT and creatinine to complete these calculations—obtain stat 1

• The clinical presentation meets diagnostic criteria for alcoholic hepatitis: jaundice, heavy alcohol use, AST/ALT ratio likely >1.5 (AST typically elevated more than ALT in alcoholic hepatitis), and bilirubin >3.0 mg/dL 1

Critical Infection Screening (Before Any Treatment)

Obtain blood cultures, urine cultures, and diagnostic paracentesis with ascitic fluid culture immediately, regardless of whether fever is present, as infection is present in 20-30% of severe alcoholic hepatitis cases and impaired neutrophil function masks typical signs. 1

• Patients with alcoholic hepatitis have profoundly impaired immune function, making them vulnerable to bacterial and fungal infections that can trigger multi-organ failure 1
• Do not start corticosteroids until active infection, hepatitis B, tuberculosis, and GI bleeding are excluded 1
• Check hepatitis B surface antigen, as hepatitis B is an absolute contraindication to corticosteroid therapy 1

Immediate Supportive Management (All Patients)

• Enforce absolute alcohol abstinence—this is the single most important intervention and cornerstone of all treatment 1

• Administer thiamine 500 mg IV three times daily for 3-5 days before any glucose-containing fluids to prevent Wernicke's encephalopathy 2

• Provide aggressive nutritional support: 1.0-1.5 g protein/kg body weight and 30-40 kcal/kg/day 1

  • If unable to eat due to anorexia or encephalopathy, place nasogastric tube for enteral feeding—parenteral nutrition alone is inadequate 1

• Avoid or minimize diuretics and all nephrotoxic drugs, as acute kidney injury is an early manifestation of multi-organ failure syndrome with very high mortality 1, 2

  • For ascites management, use cautious diuresis only if renal function permits 1

Imaging and Additional Workup

• Obtain right upper quadrant ultrasound to assess liver architecture, exclude biliary obstruction, and confirm ascites 3
• Check complete metabolic panel including albumin, and complete blood count to assess for leukocytosis, anemia, and thrombocytopenia 1
• Monitor for systemic inflammatory response syndrome (SIRS), as its presence predicts multi-organ failure 1

Corticosteroid Therapy Decision (If MDF ≥32 or MELD >20)

If MDF ≥32 or MELD >20 AND no contraindications exist (no active infection, no hepatitis B, no GI bleeding, no renal failure), start prednisolone 40 mg daily or methylprednisolone 32 mg daily. 1

• Corticosteroids provide modest survival benefit at 28 days but no benefit beyond 28 days 1

• Calculate Lille score on day 7 of corticosteroid treatment to assess response 1:

  • Lille score ≥0.45 indicates non-response—consider stopping steroids 1
  • Lille score ≥0.56 indicates null response—stop corticosteroids immediately as they provide no benefit and increase infection risk 1

• Consider adding N-acetylcysteine to corticosteroid therapy, as it may improve outcomes in severe alcoholic hepatitis 1

Alternative Therapy if Corticosteroids Contraindicated

• If active infection is present or corticosteroids are contraindicated, consider pentoxifylline as an alternative, though evidence is weaker 1

Monitoring for Complications

• Monitor closely for infections, which develop in 20-30% of cases and are the primary trigger for multi-organ failure and death 1
• Watch for hepatorenal syndrome, hepatic encephalopathy, and variceal bleeding—common decompensation events in this population 1
• Serial creatinine monitoring is essential, as rising creatinine predicts multi-organ failure 1

Liver Transplantation Consideration

• If MELD >26 or Lille score ≥0.56 (non-responder to steroids), refer urgently for liver transplantation evaluation, as 90-day mortality exceeds 70% 2, 4
• The traditional 6-month abstinence requirement may be waived in select cases of severe alcoholic hepatitis at specialized transplant centers 2

Prognosis Context

• Without treatment and continued drinking, 90-day mortality is 40-50% 1
• Even with optimal treatment, patients with severe alcoholic hepatitis and Lille score ≥0.56 have only 20-30% six-month survival 1
• The enlarged abdomen (ascites) combined with jaundice indicates decompensated cirrhosis is likely already present, as the majority of patients with alcoholic hepatitis have underlying cirrhosis at diagnosis 1