How do I diagnose and manage alcoholic hepatitis in an adult heavy drinker presenting with recent jaundice, right‑upper‑quadrant pain, fever, nausea or weight loss, including laboratory criteria (AST 2–3 × ALT, bilirubin, INR, leukocytosis), imaging findings, exclusion of other causes, severity scoring (Maddrey's Discriminant Function, MELD), and treatment options (abstinence, nutritional support, corticosteroids, pentoxifylline, management of ascites, encephalopathy, infection, transplant referral, adjunctive therapies)?

Diagnosis and Management of Alcoholic Hepatitis

Diagnosis

Alcoholic hepatitis is diagnosed clinically in patients with heavy alcohol use (>40 g/day for women, >50-60 g/day for men) for >6 months, presenting with recent-onset jaundice (bilirubin >3 mg/dL), AST >50 IU/L but <400 IU/L, AST/ALT ratio >1.5, and exclusion of other causes. 1

Clinical Presentation

• Cardinal sign: Progressive jaundice, often accompanied by fever (even without infection), malaise, tender hepatomegaly, weight loss, and signs of decompensation (ascites, encephalopathy) 1
• Patients may have stopped drinking days to weeks before symptom onset 1
• The majority of patients with alcoholic hepatitis have underlying cirrhosis at diagnosis 1, 2

Laboratory Criteria

• Bilirubin: >3 mg/dL (>50 μmol/L) 1
• AST: >50 IU/L but typically <400 IU/L (distinguishes from drug-induced liver injury and ischemic hepatitis) 1
• AST/ALT ratio: >1.5 (ratios <1.5 seen in <2% of histologically proven cases) 1
• Additional findings: Neutrophilia, prolonged INR, hypoalbuminemia, thrombocytopenia in severe cases 1

Exclusion of Other Causes

• Imaging: Obtain to exclude biliary obstruction, but avoid iodinated contrast as it significantly increases acute kidney injury risk 1, 2
• Serologic testing: Rule out viral hepatitis, severe autoimmune liver disease, and Wilson disease 1
• Infection screening: Obtain blood, urine, and ascites cultures immediately upon admission regardless of fever, as infections are common precipitants and fever/leukocytosis are unreliable indicators 1, 2

Role of Liver Biopsy

• Not required for diagnosis but useful when diagnostic uncertainty exists (10-20% may have other diagnoses) 1
• Perform via transjugular route to reduce bleeding risk 1
• Histologic features: Macrovesicular steatosis, neutrophil infiltration, hepatocyte ballooning, Mallory-Denk bodies, megamitochondria, cholestasis, and fibrosis 1

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Severity Assessment

Calculate severity using Maddrey's Discriminant Function (MDF) or MELD score immediately upon diagnosis to guide treatment decisions. 1

Prognostic Scoring Systems

• MDF >32: Predicts high 28-day mortality (20-30%); defines severe alcoholic hepatitis requiring treatment 1, 3, 4
• MELD >20: Predicts high 90-day mortality 1
• MELD >26: Consider for liver transplantation 1, 2
• Alternative scores: ABIC (category C predicts high mortality), Glasgow score (≥9 predicts high 28-day mortality) 1
• Without treatment and abstinence: 90-day mortality is 40-50% 1, 2

High-Risk Features

• SIRS on admission: Significantly increases risk of multi-organ failure with extremely high mortality 1, 2
• Acute kidney injury: Early manifestation of multi-organ failure; avoid nephrotoxic drugs including diuretics 1, 2

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Management

Immediate Hospitalization and Supportive Care

All patients with suspected severe alcoholic hepatitis (MDF >32 or MELD >20) require hospitalization for abstinence support, infection exclusion, and nutritional restoration. 1, 2

Alcohol Abstinence

• Absolute cornerstone of treatment and essential for long-term survival 1, 2
• Implement brief alcohol intervention during hospitalization (reduces future consumption by ~41 g/week) and arrange extended counseling post-discharge 2
• Consider naltrexone or acamprosate in combination with counseling to maintain abstinence after detoxification 1

Nutritional Support

Provide 35-40 kcal/kg/day with protein 1.2-1.5 g/kg/day (increase to 1.5 g/kg/day in severely ill patients); nutritional intake is a major determinant of mortality. 1, 2

• If unable to eat due to anorexia or altered mental status, use enteral feeding via nasogastric tube 1, 2
• Parenteral nutrition alone is inadequate 1, 2
• Normal-to-high protein diets are safe and do not increase encephalopathy risk 2

Infection Management

• Screen systematically for infection before initiating any immunosuppressive therapy 1, 2, 5
• Maintain high clinical suspicion as fever and leukocytosis are unreliable indicators 1, 2
• Early antibiotic treatment overlapping with corticosteroid therapy if indicated 5

Pharmacologic Treatment for Severe Disease (MDF >32 or MELD >20)

For patients without contraindications (active infection, hepatitis B, tuberculosis, gastrointestinal bleeding), consider prednisolone 40 mg daily or methylprednisolone 32 mg daily for 28 days. 1, 3

Corticosteroid Therapy

• Modest benefit: Improves 28-day mortality but provides no benefit at 90 days or 1 year, largely due to increased infection risk 2, 3, 5
• Assess response at day 7 using Lille score; discontinue if no improvement 1, 5
• Contraindications: Active infection, hepatitis B, tuberculosis, active gastrointestinal bleeding 1, 3

Combination Therapy

The combination of prednisolone plus N-acetylcysteine (NAC) intravenously over the first 5 days showed the most significant improvement in 1-month mortality (8% vs 24% with prednisolone alone) and reduced infections (19% vs 42%). 2

Alternative to Corticosteroids

• Pentoxifylline 400 mg three times daily may be considered if corticosteroids are contraindicated, though data are conflicting and evidence for corticosteroids is stronger 1, 4, 6

Management of Complications

• Ascites: Use diuretics sparingly due to acute kidney injury risk 1, 2
• Encephalopathy: Manage with standard therapies; high-protein diets are safe 2
• Acute kidney injury: Avoid nephrotoxic drugs, maintain careful fluid balance, avoid contrast dye 1, 2
• Variceal bleeding: Perform urgent endoscopy; manage per standard protocols 2

Liver Transplantation

Patients with MELD >26 who fail to respond to medical therapy should be considered for liver transplantation, which may be life-saving. 1, 2, 5

• Requires highly selected patients with good insight into their disease 1
• Emerging role with improved patient selection methods 5

Patients with Non-Severe Disease (MDF <32, MELD <20)

• Supportive care and abstinence are sufficient; pharmacologic therapy is less urgent 1
• Monitor for improvement with decrease in bilirubin during hospitalization 1

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Common Pitfalls

• Failing to screen for infection before initiating corticosteroids leads to increased mortality 1, 2
• Using diuretics aggressively precipitates acute kidney injury and multi-organ failure 1, 2
• Continuing corticosteroids beyond day 7 in non-responders (Lille score) wastes resources and increases infection risk 1, 5
• Inadequate nutritional support (<21.5 kcal/kg/day) significantly reduces survival 2
• Relying on fever or leukocytosis to diagnose infection misses many cases in this immunocompromised population 1, 2