Alcoholic hepatitis

Question 1

Define alcoholic hepatitis

Answer 1

Inflammatory liver injury caused by the chronic heavy intake of alcohol

Is stage 2 of alcoholic liver disease ((1) fatty liver/steatosis, (2) alcoholic hepatitis, (3) liver cirrhosis)

Question 2

Aetiology of alcoholic hepatitis

Answer 2

Alcohol metabolism in the liver produces excess NADH, which inhibits gluconeogenesis and fatty acid oxidation
A threshold amount for alcohol ingestion is about 40-80 g/day in men and 20-40 g/day in women for 10-12 years

Histology shows hepatocyte damage (centrilobular balloon cells, Mallory hyaline, neutrophils and lymphocytes), inflammation and fibrosis + collagen surrounding hepatocytes, fatty changes and mega mitochondria

Question 3

Risk factors for alcoholic hepatitis

Answer 3

Alcohol misuse - prolonged and heavy consumption
Co-existent liver diseases e.g. Hep B or C
Female
Smoking
Obesity (BMI >30)
>65
Genetic predisposition e.g. haemochromatosis, Wilson’s, alpha-1 antitrypsin deficiency, cystic fiboris s
Budd-chiari syndrome

Question 4

Symptoms of alcoholic hepatitis

Answer 4

Illness
Nausea
Malaise
Epigastric or right hypochondrial pain
Low grade fever

Question 5

Signs of alcoholic hepatitis on examination

Answer 5

General exam
- Malnourished
Abdominal exam
- Palmar erythema
- Dupuytren’s contracture
- Facial telangiectasia
- Parotid enlargement
- Spider naevi
- Gynaecomastia
- Hepatomegaly
- Easy bruising
Pelvic exam
- Testicular atrophy

Question 6

Symptoms and signs of severe alcoholic hepatitis

Answer 6

Jaundice
Abdominal discomfort and swelling (RUQ pain)
Swollen ankles
GI bleed -> haematemesis or PR bleeding (melaena)
Nausea and vomiting

General and obs
- Febrile (50%)
- Tachycardia
- Drowsiness - Unable to copy and 5 point star, disorientated
- Peripheral neuropathy
Abdominal exam
- Jaundice
- Asterixis (signs of encephalopathy)
- Telengiectasia
- Ascites
- Hepatomegaly
- Splenomegaly

Question 7

Investigations for alcoholic hepatitis

Answer 7

LFTs: AST/ALT raised (AST/ALT ratio >2), GGT raised, bilirubin raised, albumin reduced, ALP raised
Clotting: PT prolonged
FBC: macrocytic anaemia, raised WCC, reduced platelets
U&Es: Urea, K low

US: normal OR hepatomegaly/fatty liver/cirrhosis/splenomegaly/ascites/portal HTN
Liver biopsy (perc or transjugular): Steatosis, inflammation, neutrophils + lymphocytes, ballooning hepatocytes, Mallory hyaline bodies, fibrosis, collagen surrounded hepatocytes

Question 8

Management for alcoholic hepatitis

Answer 8

Nutrition
- Nutritional support with oral or nasogastric feeding
- Nutritional supplementation with thiamine, vitamin B, folic acid parenteral then oral

Long term:
- Advise drinking cessation
- Supportive care - alcohol abstinence counselling, intervention, AAA, rehab programmes
- Smoking cessation
- Weight reduction
- Influenza and pneumococcal vaccination

Question 9

Complications of alcoholic hepatitis

Answer 9

Cirrhosis → liver failure
Hepatic encephalopathy
Portal HTN
GI bleeding
Coagulopathy
Renal failure
Hepatomegaly syndrome
Hepatocellular carcinoma
Sepsis

Question 10

Prognosis for alcoholic hepatitis

Answer 10

Mortality in the first month is 10%, first year is 40%
Short-term outlook for those with alcoholic fatty liver is excellent (usually reverts to normal with abstinence)
Progression to liver cirrhosis within 1-3 years
Prognostic scores: Maddrey’s discrimination function (MDF), Glasgow alcoholic hepatitis score (GAHS)