In a 36-year-old man with two weeks of jaundice and malaise, heavy daily vodka consumption, markedly elevated aspartate aminotransferase and alanine aminotransferase, hyperbilirubinemia, leukocytosis, mild thrombocytopenia, coagulopathy (elevated international normalized ratio), mildly impaired renal function, fatty liver on ultrasound, and blood cultures already drawn, what is the most appropriate next step in management?

Confirm Negative Blood Cultures and Start Prednisolone

The most appropriate next step is to confirm that blood cultures are negative (and screen for other infections), then initiate prednisolone 40 mg daily if no contraindications exist. This patient presents with severe alcoholic hepatitis requiring immediate severity stratification and consideration for corticosteroid therapy.

Immediate Severity Assessment

Calculate the Maddrey Discriminant Function (mDF) using the formula: 4.6 × (patient PT - control PT) + total bilirubin (mg/dL). 1, 2

With this patient's presentation:

• INR 1.9 (approximately PT prolongation of ~5-7 seconds above control)
• Bilirubin 12.4 mg/dL
• Estimated mDF ≈ 35-40 (well above the threshold of 32)

This defines severe alcoholic hepatitis with an expected 40-50% mortality at 90 days without treatment. 1, 2

The MELD score should also be calculated using bilirubin (12.4), INR (1.9), and creatinine (1.4), which would yield approximately MELD 24-26, further confirming severe disease (>20 indicates high mortality). 1, 2

Why This Patient Has Severe Alcoholic Hepatitis

The clinical presentation is classic: 1, 3

• Heavy daily alcohol consumption (≥750 mL vodka = ~300g ethanol/day, far exceeding the 40g/day threshold)
• Jaundice with bilirubin >5 mg/dL
• AST/ALT ratio >1 (2300/1800 = 1.28), though the absolute values are higher than typical for alcoholic hepatitis
• Leukocytosis (18,000) without documented infection
• Coagulopathy (INR 1.9)
• Hepatomegaly with fatty infiltration

Critical Infection Screening Before Steroids

Do NOT start corticosteroids until active infection is definitively excluded. 1, 2

Infection is present in 20-30% of severe alcoholic hepatitis cases and is the primary trigger for multi-organ failure and death. 2 Patients have profoundly impaired immune function making them vulnerable to bacterial and fungal infections. 2

Required screening includes: 1, 2, 3

• Confirm negative blood cultures (already obtained)
• Chest X-ray to exclude pneumonia
• Urinalysis and urine culture
• Diagnostic paracentesis if any ascites present (not clearly documented here, but ultrasound should clarify)

Also exclude: 1, 2

• Active GI bleeding
• Hepatitis B, hepatitis C
• Tuberculosis
• HIV (if risk factors present)

Why NOT the Other Options

Tylenol level: While acetaminophen toxicity can cause marked transaminase elevation (often >1000-3000 IU/L), the clinical context strongly favors alcoholic hepatitis. The AST/ALT ratio >1, chronic heavy alcohol use, leukocytosis, and 2-week duration make acetaminophen toxicity unlikely. However, if there is ANY history of acetaminophen use, checking a level is reasonable. 1, 4

IV N-acetylcysteine alone: NAC may be used as an adjunct to prednisolone in severe alcoholic hepatitis (some evidence suggests modest benefit when combined with steroids), but it is not first-line monotherapy. 1, 5 NAC is primarily indicated for acetaminophen toxicity, which this is not.

ERCP: There is no indication for ERCP. The ultrasound shows fatty infiltration and hepatomegaly without biliary obstruction. The cholestasis is intrahepatic from severe alcoholic hepatitis, not obstructive. 1

MRI/MRCP: Unnecessary at this point. The diagnosis is clear from clinical presentation, laboratory values, and ultrasound findings. Imaging would delay critical treatment. 1, 3

Corticosteroid Therapy Protocol

If infections are excluded, start prednisolone 40 mg daily (or methylprednisolone 32 mg daily). 1, 2, 5, 3

• Corticosteroids provide modest survival benefit at 28 days in severe alcoholic hepatitis (mDF ≥32 or MELD >20). 2, 5
• Calculate the Lille score on day 7 to assess response. 1, 2
• If Lille score ≥0.45, steroids are ineffective and should be stopped. 1, 2
• Continue for 28 days total if Lille <0.45 indicates response. 1, 2

Essential Supportive Measures

Thiamine 500 mg IV three times daily for 3-5 days before any glucose-containing fluids to prevent Wernicke's encephalopathy. 2, 6

Aggressive nutritional support: 1, 2, 6

• 1.0-1.5 g protein/kg body weight
• 30-40 kcal/kg/day
• Enteral nutrition goal >21 kcal/kg

Absolute alcohol abstinence is the single most important intervention and cornerstone of all treatment. 2, 6, 4

Critical Pitfall

The elevated creatinine (1.4 mg/dL) indicates early acute kidney injury, likely hepatorenal syndrome given the clinical context. 1 While creatinine >2.5 mg/dL is a contraindication to steroids, this patient is below that threshold. However, close monitoring for progression is essential, as AKI significantly worsens prognosis. 1 Avoid nephrotoxins and use diuretics cautiously. 1

Prognosis

Without treatment and continued drinking, 90-day mortality is 40-50%. 2 Even with optimal corticosteroid therapy, only about 50% of patients respond. 5, 3 Long-term survival depends entirely on sustained alcohol abstinence. 2, 5, 3