Alcoholic Hepatitis

Alcoholic Hepatitis – Alex Wiles, Julie Cui

Background

  • Acute onset of rapidly progressive jaundice in pt with heavy EtOH intake (>40g in females or >60g in males EtOH/day for >6 mos, or within <60 days of abstinence).
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    • May present after they have quit drinking due to immunosuppressive effects of alcohol.
    • 20-50% Mortality in hospitalized AH pts

 

Evaluation

  • AST >60, AST/ALT >1.5, both values <400 IU/L; TBili >3.0 mg/dL, documentation of heavy EtOH use until 8 weeks prior to presentation
  • Prognostication with Maddrey’s Discriminant Function: 4.6 * (PTpt – PTctrl) + Tbili
    • Maddrey > 32 = poor 30d prognosis & may benefit from steroids (see below)
  • RUQ to rule out obstructive cause of jaundice
  • Biopsy is not typically required but will show neutrophilic lobular inflammation, hepatocyte ballooning, steatosis, and pericellular fibrosis.
  • Phosphatidylethanol (PEth) level is a biomarker of ethanol consumption over ~ 4wks; >20 ng/mL can indicate chronic moderate/heavy alcohol intake
    • A single episode consumption can result in detectable Peth for up to 12 days. Can be elevated for months with regular heavy alcohol intake.
    • In some studies, 99% sensitive and specific for alcoholism.
    • EtOH levels may be negative unless acutely intoxicated
       

Management

  • Supportive Care is essential! Consult Nutrition, start High protein, high calorie diet, high dose Thiamine x 3d, Folate, MVI
  • Full infection workup (CXR, UA, BCx, paracentesis) regardless of sxs
  • Steroids: STOP-AH Trial (NEJM 2015) showed improved mortality at 28 days but not at 90 days in patients with Maddrey > 32 who received steroids; the decision to treat is very nuanced and should be discussed with hepatology attending
    • Contraindications to steroids include: presence of infection (must rule out first including TB, uncontrolled GI bleeding, AKI w/ Cr >2.5 mg/dL)​​​​​​​
    • Prednisolone 40mg daily for pts who meet above criteria (2018 ACG Guidelines)
    • The Lille score can be used to guide continuation or d/c  of steroids after 7 d of therapy
    • NAC can be considered as adjunctive therapy to steroids and may decrease 30-day mortality, though has not demonstrated longer mortality benefit at 3 nor 6 months
    • Recent analysis from STOP AH data has demonstrated that pts with neutrophil to lymphocyte ratio (NLR) 5-8 prior to steroids most likely to benefit from steroids
  • Monitor on CIWA
    • Psychiatry consultation as appropriate, consideration of medical therapy
      • Disulfiram and naltrexone are both metabolized by the liver and can cause hepatic toxicity and therefore are not used in this population
      • Baclofen has been shown to improve alcohol abstinence in pts with EtOH cirrhosis
      • Acamprosate has not been studied in this population but can be considered
      • Gabapentin has also demonstrated efficacy and can be given up to 1200mg for AUD

 

Liver transplantation

  • Current VUMC policy: pts should be abstinent for no less than 3-6 months, although exceptions may be made for early liver transplant based on a very strict protocol
    • Sustained Alcohol use post- Liver Transplant (SALT) score 6
      • +4 points if >10 drinks/day at initial hospitalization
      • +4 points if multiple prior rehab attempts
      • +2 points if prior alcohol related legal issues
      • +1 points if prior illicit substance abuse
  • “Exceptions:” Severe AH as first liver-decompensating event in patients who are not expected to survive to complete treatment
    • Presence of strong sober social support
    • Absence of severe uncontrolled coexisting psychiatric disorders
    • Agreement by patient and family to adhere therapy and lifelong abstinence