What are the parameters for admitting a patient with alcoholic liver disease?

Hospital Admission Parameters for Alcoholic Liver Disease

Patients with alcoholic liver disease should be hospitalized when they present with severe alcoholic hepatitis (Maddrey Discriminant Function ≥32 or MELD >20), any signs of hepatic decompensation (ascites, hepatic encephalopathy, variceal bleeding, or jaundice), or when they lack adequate social/medical support to ensure abstinence and proper nutrition. 1

Severity-Based Admission Criteria

Severe Alcoholic Hepatitis (Immediate Admission Required)

Calculate severity scores immediately upon presentation:

• Maddrey Discriminant Function (MDF) ≥32 indicates severe disease with 30-50% mortality at 28 days without treatment 1, 2
• MELD score >20 defines severe alcoholic hepatitis with high 90-day mortality risk 3, 1, 4
• These patients require hospitalization for corticosteroid therapy consideration and intensive monitoring 1

Clinical Decompensation (Mandatory Admission)

Any of the following complications warrant immediate hospitalization:

• Ascites - typically the first complication, occurring in ~20% of patients within the first year after diagnosis 5
• Hepatic encephalopathy - associated with the highest mortality among decompensation events and predicts poor 5-year survival 5, 6
• Variceal bleeding - occurs in ~6% of patients in the first year, with increased risk in those continuing alcohol use 5
• Jaundice with rapid onset - defined as serum bilirubin >3 mg/dL, particularly when developing over <60 days 3

Laboratory-Based Admission Triggers

Admit patients presenting with:

• AST >50 IU/mL with AST/ALT ratio >1.5 in the context of recent heavy alcohol use 3, 7
• Elevated bilirubin >3 mg/dL with clinical suspicion of alcoholic hepatitis 3
• Evidence of coagulopathy (elevated INR) suggesting synthetic dysfunction 5
• Leukocytosis with fever - may indicate severe alcoholic hepatitis or concurrent infection 1

Additional Admission Indications

Social and Support Factors

Hospitalize patients who:

• Lack adequate social or medical support to ensure alcohol abstinence 1
• Cannot maintain proper nutrition at home (require 1-1.5g protein and 30-40 kcal/kg body weight daily) 1
• Have anorexia or altered mental status preventing adequate oral intake 1

Intermediate Severity Disease

Even patients with "moderate" alcoholic hepatitis (MDF <32) require careful consideration for admission:

• These patients have substantial mortality: 10% at 6 months and 20% at 1 year 1
• Approximately 50% 5-year mortality in patients with decompensated disease and MDF <32 6
• Presence of hepatic encephalopathy at baseline is a critical predictor of poor long-term survival, warranting admission for close monitoring 6

Infection Screening (Critical for All Admissions)

All hospitalized patients with alcoholic liver disease require:

• Blood, urine, and ascites cultures (if present) regardless of fever presence 1
• Patients with alcoholic cirrhosis are particularly prone to bacterial infections 5
• Early identification and treatment of infections is essential as they can precipitate multi-organ failure 1

Common Pitfalls to Avoid

Do not discharge patients based solely on MDF <32 - these patients still have significant mortality risk and may benefit from inpatient nutritional support and abstinence counseling 1, 6

Do not delay severity assessment - calculate both MDF and MELD scores immediately upon presentation, as early stratification is crucial for timely intervention 3, 1

Do not overlook concurrent organ damage - screen for alcoholic cardiomyopathy, IgA nephropathy, peripheral neuropathy, and chronic pancreatitis in all admitted patients 5

Avoid nephrotoxic agents including diuretics in the acute setting, as acute kidney injury is an early manifestation of multi-organ failure 1

Risk Stratification Algorithm

1. Obtain detailed alcohol history: >40g/day for women, >50-60g/day for men, typically >6 months with <60 days abstinence before jaundice 3
2. Calculate MDF: 4.6 × (PT patient - PT control) + total bilirubin (mg/dL) 5
3. Calculate MELD score for additional prognostic information 5, 1
4. Assess for decompensation: ascites, encephalopathy, variceal bleeding, jaundice 5
5. Evaluate social support for outpatient abstinence and nutrition 1

If MDF ≥32, MELD >20, any decompensation present, or inadequate social support → ADMIT 1