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

Management of Alcoholic Hepatitis

Alcohol abstinence is the absolute cornerstone of treatment for all patients with alcoholic hepatitis, and patients with severe disease (Maddrey discriminant function >32 or MELD >20) should receive prednisolone 40 mg daily for 28 days unless contraindications exist. 1, 2

Initial Assessment and Risk Stratification

Severity scoring must be performed immediately to guide treatment decisions and predict mortality risk. 1, 2

• Calculate disease severity using Maddrey discriminant function (MDF) >32, MELD score >20, ABIC score category C, or Glasgow alcoholic hepatitis score ≥9—all predict high short-term mortality (28-90 days) without treatment 1, 3
• Screen for infections immediately with blood cultures, urine cultures, and ascitic fluid cultures (if ascites present) regardless of whether fever is present, as infections dramatically worsen outcomes 1, 3
• Obtain liver imaging but avoid iodinated contrast agents due to acute kidney injury risk 1, 3
• Recognize that most patients already have cirrhosis at the time of alcoholic hepatitis diagnosis, and jaundice represents decompensation with 40-50% mortality at 90 days without treatment and abstinence 1

Universal Treatment Components (All Patients)

Alcohol Abstinence

• Mandate complete and permanent abstinence as there is no safe amount of alcohol consumption after alcoholic hepatitis 2
• Prescribe naltrexone or acamprosate in combination with counseling to reduce relapse risk in patients who achieve abstinence 2
• Consider baclofen as an alternative pharmacologic agent for maintaining abstinence 1

Aggressive Nutritional Support

• Provide 30-40 kcal/kg/day and 1.2-1.5 g protein/kg/day through enteral feeding, as this improves survival regardless of steroid treatment 1, 2
• Place a feeding tube if the patient cannot eat due to anorexia or altered mental status—parenteral nutrition alone is inadequate 1
• Supplement with vitamins and minerals including thiamine, vitamin B12, folic acid, pyridoxine, vitamin D, and zinc 1

Critical Supportive Measures

• Avoid or minimize nephrotoxic drugs including diuretics, as acute kidney injury is an early manifestation of multi-organ failure syndrome 1, 2, 3
• Monitor for systemic inflammatory response syndrome (SIRS) on admission, as this predicts multi-organ failure with very high mortality 1

Treatment Based on Disease Severity

Severe Alcoholic Hepatitis (MDF ≥32 or MELD >20)

Prednisolone 40 mg daily (or methylprednisolone 32 mg IV) for 28 days is the first-line pharmacologic treatment for severe disease. 1, 2, 3

Before Starting Steroids:

• Rule out contraindications: active gastrointestinal bleeding, uncontrolled infection, hepatitis B infection, tuberculosis, renal failure, or acute pancreatitis 1, 2, 4
• Ensure negative infection screening as noted above 4

Steroid Response Assessment at Day 7:

• Calculate the Lille score at day 7 using age, albumin at day 0, change in bilirubin from day 0 to day 7, renal function, bilirubin at day 0, and prothrombin time 3, 4
• If Lille score <0.45: Continue prednisolone for full 28 days (85% 6-month survival expected) 3, 4
• If Lille score ≥0.56: Stop prednisolone immediately—these patients derive no benefit and only face increased infection risk (53.3% 28-day survival) 4
• If Lille score 0.45-0.56: Consider stopping on a case-by-case basis (79.4% 28-day survival) 4

Critical Monitoring During Steroid Treatment:

• Screen repeatedly for infections, as 25% of patients develop infections during the first month of corticosteroid treatment, and infection under steroids increases short-term mortality 4
• Recognize that clinical deterioration during hospitalization indicates very high infection risk requiring repeated cultures 4

Important Limitations of Steroids:

• Methylprednisolone does not improve survival beyond 28 days, and benefits even within 28 days are modest 1
• Continuing steroids in non-responders (Lille ≥0.56) is a critical error that exposes patients to infection without survival benefit 4

Alternative to Steroids (If Contraindications Exist)

• Pentoxifylline 400 mg three times daily with meals may be used if glucocorticoids are contraindicated, though data regarding efficacy are conflicting 1
• Note that pentoxifylline should not be used as an adjunct to corticosteroids, as multiple large trials show no survival benefit and no reduction in hepatorenal syndrome 4

Mild to Moderate Alcoholic Hepatitis (MELD <20 and MDF <32)

• Refer for abstinence counseling and implement brief interventions to encourage controlled drinking or abstinence 1
• Prescribe high-protein diet supplemented with B vitamins and folic acid 1
• Provide nutritional support as outlined above 1

Liver Transplantation Consideration

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

• The 90-day mortality rate is very high in this population without transplantation 1
• Early liver transplantation in carefully selected patients provides significant survival benefit with 6-month survival rates of 77-100%, comparable to transplantation for other indications 5
• Traditional 6-month abstinence requirement cannot be met by most patients with severe alcoholic hepatitis who fail medical therapy 5, 6

Common Pitfalls to Avoid

• Do not continue steroids beyond day 7 in non-responders (Lille ≥0.56)—this only increases infection risk without benefit 4
• Do not use diuretics liberally—acute kidney injury heralds multi-organ failure 1, 2
• Do not rely on parenteral nutrition alone—enteral feeding is essential 1
• Do not miss occult infections—culture aggressively even without fever 1, 3
• Do not delay transplant evaluation in severe disease with MELD >26 and steroid non-response 1, 4