From the Guidelines
Alcoholic hepatitis diagnosis should be suspected in patients with a history of heavy alcohol use who present with jaundice, fever, right upper quadrant pain, and hepatomegaly, and confirmed through a combination of clinical assessment, laboratory tests, and sometimes liver biopsy, as recommended by the most recent guidelines 1. The diagnosis of alcoholic hepatitis is based on a combination of clinical and laboratory findings, including:
- History of heavy alcohol use
- Jaundice
- Fever
- Right upper quadrant pain
- Hepatomegaly
- Elevated liver enzymes with AST often higher than ALT (AST:ALT ratio >2)
- Elevated bilirubin
- Prolonged prothrombin time
- Leukocytosis The Maddrey's Discriminant Function (DF) is commonly used to assess severity, with a score ≥32 indicating severe disease, as stated in the guidelines 1. Other scoring systems include the MELD score, Glasgow Alcoholic Hepatitis Score, and ABIC score. While liver biopsy is the gold standard for diagnosis, it's not always necessary and is typically reserved for cases where the diagnosis is uncertain or to rule out other causes of liver disease, as recommended by the guidelines 1. Imaging studies like ultrasound, CT, or MRI can help exclude other causes of liver disease but aren't diagnostic for alcoholic hepatitis. Early diagnosis is crucial as severe alcoholic hepatitis carries a high mortality rate, and appropriate treatment with corticosteroids or pentoxifylline may be indicated in severe cases, along with nutritional support and alcohol abstinence, as recommended by the guidelines 1. Some key points to consider in the diagnosis and management of alcoholic hepatitis include:
- The use of prognostic scores to identify severe forms of AH, at risk of early mortality 1
- The consideration of corticosteroids in patients with severe AH to reduce short-term mortality, but not influencing medium to long-term survival 1
- The importance of systematic screening for infection before initiating therapy, during corticosteroid treatment, and during the follow-up period 1
- The identification of early non-response to corticosteroids and the application of strict rules for the cessation of therapy 1
- The consideration of early liver transplantation in highly selected patients with non-response to corticosteroids 1
From the Research
Diagnosis of Alcoholic Hepatitis
- Alcoholic hepatitis is a clinical syndrome characterized by acute-onset jaundice and liver enzyme abnormalities in the setting of long-term heavy alcohol use 2
- Diagnosis is primarily clinical, based on a consensus definition from the National Institute on Alcohol Abuse and Alcoholism 2
- Initial workup should include chest radiography and cultures of peritoneal fluid, blood, and urine 2
- Laboratory-based prognostic scores, including Maddrey Discriminant Function and the Model for End-Stage Liver Disease, help determine disease severity and treatment options 2
Clinical Features and Laboratory Results
- Patients with alcoholic hepatitis usually have a history of drinking heavily for many years 3
- Symptoms could be mild and nonspecific to more severe 4
- Liver biopsy is confirmatory but generally not indicated for the diagnosis 4
- Several clinical scoring systems have been derived to predict the clinical outcomes of patients with AH; such as Child-Turcotte-Pugh score, the Maddrey discriminant function, the Lille Model, the model for end stage liver disease scores, and the Glasgow alcoholic hepatitis score 5
Treatment Options
- Abstinence is the key form of therapeutic intervention 4
- Corticosteroids or pentoxifylline are the current pharmacologic treatment options; though the outcomes from the therapies are poor 5
- Corticosteroids are recommended for severe alcoholic hepatitis 2
- Responsiveness to corticosteroid therapy should be evaluated using the Lille score on day 7 of treatment 2
- Liver transplantation as the treatment of alcoholic hepatitis remains controversial 5