What are the implications of elevated total bilirubin (bili) and aspartate aminotransferase (AST) due to alcohol consumption?

From the Guidelines

Elevated total bilirubin and AST levels in the context of alcohol consumption necessitate immediate cessation of alcohol intake and supportive care to prevent further liver damage and potentially fatal complications. The most critical intervention is complete abstinence from alcohol, as continued drinking will exacerbate liver injury 1. Supportive care should include maintaining adequate hydration, ensuring proper nutrition with an emphasis on B vitamins (particularly thiamine 100mg daily), and monitoring liver function tests every 2-4 weeks until improvement occurs. For patients experiencing withdrawal symptoms, a benzodiazepine taper may be necessary under medical supervision. Medications like acamprosate (666mg three times daily) or naltrexone (50mg daily) can help maintain abstinence.

Key Considerations

• The diagnosis of acute alcoholic hepatitis (AH) should be considered in adults with rapid onset of jaundice and elevated serum AST levels, a history of drinking more than 40 g (3 standard drinks) of ethanol daily for more than 1 year 1.
• Criteria for diagnosing AH include onset of jaundice within 8 weeks of last period of drinking, heavy drinking for more than 6 months, serum bilirubin > 3.0 mg/dL, serum AST > 50 IU/L but < 400 IU/L, and serum AST/ALT ratio > 1.5 1.
• Assessing the severity of AH is crucial, with tools like the Maddrey discriminant function (MDF), MELD score, ABIC score, and Glasgow alcoholic hepatitis score helping to predict mortality rates 1.
• Patients with severe AH or inadequate social and medical support should be admitted to the hospital to encourage abstinence, restore adequate nutrition, and exclude serious infections 1.

Management and Prognosis

• Abstinence from alcohol is the cornerstone of treatment for AH, and patients should be encouraged to abstain completely from drinking, with support and encouragement even if they fail to achieve abstinence, as a reduction in alcohol consumption improves survival 1.
• For patients with severe AH, particularly those with a MELD score > 26, referral for evaluation for liver transplantation should be considered, given the high 90-day mortality rate 1.
• Patients with mild to moderate AH should be referred for abstinence counseling and prescribed a high protein diet supplemented with B vitamins and folic acid 1.
• The presence of systemic inflammatory response syndrome (SIRS) on admission is associated with an increased risk of multi-organ failure syndrome, which has a very high mortality rate 1.

Monitoring and Follow-Up

• Regular monitoring of liver function tests and clinical assessment for signs of liver failure or decompensation is essential in managing patients with alcohol-related liver injury 1.
• Patients should be educated on the importance of abstinence, proper nutrition, and adherence to prescribed medications to improve outcomes and prevent complications.

From the Research

Elevated Total Bilirubin and AST from Alcohol

• Elevated total bilirubin and AST (aspartate aminotransferase) levels can be associated with alcohol consumption, as seen in a study where acute alcohol consumption elevated serum bilirubin, an endogenous antioxidant 2.
• The elevation of AST and ALT (alanine aminotransferase) levels can indicate hepatocellular injury, with the degree of elevation guiding the evaluation of liver disease 3.
• An ASAT/ALAT ratio greater than 1.5 can be considered highly suggestive of an alcoholic etiology of liver injury 4.
• The use of test combinations, such as the ratio of GGT (gamma-glutamyltransferase) to alkaline phosphatase, can improve the diagnostic value of serum enzyme determinations in detecting alcohol-related liver injury 4.

Diagnostic Considerations

• The evaluation of hepatocellular injury includes testing for viral hepatitis, nonalcoholic fatty liver disease, alcoholic liver disease, and other conditions 3.
• A history of prescribed and over-the-counter medicines should be sought, as well as screening for hereditary hemochromatosis, autoimmune hepatitis, Wilson's disease, and alpha-1 antitrypsin deficiency 3.
• A liver biopsy may be considered when serologic testing and imaging fail to elucidate a diagnosis, to stage a condition, or when multiple diagnoses are possible 3.

Treatment and Management

• Timely administration of thiamine is critical in the treatment of Wernicke's encephalopathy, a condition associated with thiamine deficiency and often caused by alcoholism 5, 6.
• The route and dosage of thiamine administration remain controversial, and clinical judgment should be exercised in diagnosis and treatment 5, 6.