What is the treatment approach for a patient with severe alcoholic hepatitis on decompensated cirrhosis, portal hypertension, ascites, bilateral pitting pedal edema, systemic inflammation, probable occult infection, severe hypokalemia, and dilutional hyponatremia?

Treatment of Severe Alcoholic Hepatitis with Decompensated Cirrhosis

This patient requires immediate hospitalization with aggressive infection screening, cautious fluid/electrolyte management, consideration of corticosteroids only after excluding infection, and urgent liver transplant evaluation given the extremely high mortality risk. 1

Immediate Priorities: Infection Exclusion and Hemodynamic Stabilization

Mandatory Infection Workup Before Any Immunosuppression

• Obtain blood, urine, and ascitic fluid cultures immediately, regardless of fever presence, as bacterial infections are the primary contraindication to corticosteroid therapy and occur frequently in this population 1
• Systemic inflammation with probable occult infection makes corticosteroids potentially lethal until infection is definitively ruled out 1
• The immune response is already impaired in severe alcoholic hepatitis, placing patients at extreme risk for multi-organ failure if infections develop 1

Critical Electrolyte and Fluid Management

• Correct severe hypokalemia aggressively with potassium chloride supplementation, as hypokalemia in cirrhotic ascites can precipitate hepatic encephalopathy and cardiac arrhythmias 1
• Do NOT restrict fluids for dilutional hyponatremia unless serum sodium drops below 120-125 mmol/L, as excessive fluid restriction worsens malnutrition which is already critical in alcoholic hepatitis 1, 2
• Dilutional hyponatremia reflects advanced portal hypertension with splanchnic vasodilation and is managed by treating the underlying cirrhosis, not by fluid restriction in most cases 3, 4
• Avoid or use diuretics extremely sparingly, as nephrotoxic drugs including diuretics precipitate acute kidney injury, which is an early manifestation of multi-organ failure syndrome with very high mortality 1, 5

Ascites and Volume Management Strategy

Diuretic Therapy Approach

• If diuretics must be used, start spironolactone 100 mg daily (maximum 400 mg/day) with or without furosemide 40 mg daily (maximum 160 mg/day) in a 100:40 ratio 1, 2
• Monitor closely for diuretic-induced complications: worsening renal function (creatinine >2 mg/dL), further hyponatremia (sodium <125 mmol/L), or potassium abnormalities (<3 or >6 mmol/L) 1
• In severe alcoholic hepatitis with systemic inflammation, the risk of acute kidney injury from diuretics often outweighs benefits 1

Large Volume Paracentesis Considerations

• For tense ascites causing respiratory compromise, perform therapeutic paracentesis with albumin replacement (8 g albumin per liter removed) 1, 2
• Avoid large volume paracentesis without albumin in the setting of severe alcoholic hepatitis, as this can precipitate hepatorenal syndrome 6

Nutritional Support: Non-Negotiable Priority

• Provide 1.0-1.5 g protein/kg/day and 30-40 kcal/kg/day immediately, as adequate nutrition is essential for recovery and survival 1, 2
• If oral intake is inadequate due to anorexia or altered mental status, place a feeding tube for enteral nutrition—parenteral nutrition alone is inadequate 1
• Supplement thiamine, folate, and other vitamins to prevent Wernicke's encephalopathy and address micronutrient deficiencies 5

Corticosteroid Decision: Only After Infection Exclusion

Severity Assessment

• Calculate MELD score and Maddrey Discriminant Function (MDF) to determine severity 1
• MDF >32 or MELD >20 defines severe alcoholic hepatitis with 40-50% mortality at 90 days without treatment 1

Corticosteroid Criteria and Contraindications

• If cultures are negative and no contraindications exist (hepatitis B, tuberculosis, active infection), consider methylprednisolone 32 mg daily 1
• The benefit is modest and limited to <28 days; methylprednisolone does not improve survival beyond 28 days 1
• Presence of SIRS (systemic inflammatory response syndrome) on admission increases risk of multi-organ failure syndrome, making corticosteroid use even more controversial 1
• Given "probable occult infection" in this case, corticosteroids should be withheld until infection is definitively excluded 1

Alternative to Corticosteroids

• If infection cannot be excluded or corticosteroids are contraindicated, use pentoxifylline 400 mg three times daily with meals, though efficacy data are conflicting 1

Medications to Absolutely Avoid

• NSAIDs are absolutely contraindicated—they reduce urinary sodium excretion, precipitate renal dysfunction, and convert diuretic-sensitive ascites to refractory ascites 1, 2, 5
• ACE inhibitors and angiotensin receptor blockers must be discontinued immediately—they worsen hypotension and can precipitate hepatorenal syndrome 2, 5
• Beta-blockers should be held during acute decompensation, as they can precipitate hemodynamic collapse 6, 5
• Avoid nephrotoxic drugs and iodinated contrast dye, which increases acute kidney injury risk 1

Alcohol Abstinence: The Single Most Critical Intervention

• Complete and permanent alcohol cessation is mandatory and more impactful than any pharmacologic therapy, improving 3-year survival from 0% to 75% 1, 5
• Abstinence is the cornerstone of treatment and can lead to "re-compensation" of decompensated cirrhosis 1, 6
• Without abstinence, mortality within 90 days is 40-50% even with treatment 1

Urgent Liver Transplant Evaluation

• Patients with MELD >26 should be referred immediately for liver transplant evaluation, as 90-day mortality is extremely high 1
• Several studies demonstrate that outcomes of liver transplantation in severe alcoholic hepatitis are similar to other etiologies with comparable MELD scores 1
• Transplant centers require good insight into alcohol use disorder and strong social support, but some centers are moving away from mandatory abstinence periods given the high mortality 1

Monitoring for Complications

Hepatic Encephalopathy

• Start lactulose empirically if any mental status changes occur, as hepatic encephalopathy has the highest mortality among decompensation complications 1, 6, 5
• Avoid precipitants: hypokalemia, infections, gastrointestinal bleeding, excessive diuresis 1

Spontaneous Bacterial Peritonitis Surveillance

• Perform diagnostic paracentesis on admission and with any clinical deterioration—ascitic neutrophil count >250/mm³ confirms SBP 2
• Start empirical antibiotics immediately if SBP is suspected (ceftriaxone 1 g daily for up to 7 days in advanced cirrhosis) 2, 6

Acute Kidney Injury Prevention

• Monitor creatinine daily—rising creatinine with oliguria signals multi-organ failure with very high mortality 1
• Acute kidney injury is an early manifestation of multi-organ failure syndrome in severe alcoholic hepatitis 1

Common Pitfalls to Avoid

• Do not initiate diuretic therapy aggressively in severe alcoholic hepatitis—the risk of precipitating hepatorenal syndrome and multi-organ failure outweighs benefits 1, 7
• Do not start corticosteroids before excluding infection—this can precipitate fatal sepsis in immunocompromised patients 1
• Do not restrict fluids for dilutional hyponatremia unless sodium <120-125 mmol/L—this worsens malnutrition and outcomes 1, 2
• Sudden alterations of fluid and electrolyte balance can precipitate hepatic coma—strict observation is necessary during any diuresis 7
• Avoid excessive bed rest, as it causes muscle atrophy and worsens sarcopenia 2

Prognosis and Realistic Expectations

• Without treatment and abstinence, 90-day mortality is 40-50% 1
• Even with optimal treatment, 1-year mortality approaches 56% in severe alcoholic hepatitis 1
• The presence of systemic inflammation with multi-organ failure carries a very high mortality rate 1
• Liver transplantation remains the definitive treatment for those with MELD >26 who meet criteria 1