Alcoholic Hepatitis

Question 1

Define alcoholic hepatitis

Answer 1

Inflammatory liver injury caused by chronic heavy intake of alcohol

Question 2

Explain the aetiology / risk factors of alcoholic hepatitis

Answer 2

One of the THREE forms of liver disease caused by excessive alcohol intake - the spectrum consists of:
Alcoholic fatty liver (steatosis)
Alcoholic hepatitis
Chronic cirrhosis

Question 3

Summarise the epidemiology of alcoholic hepatitis

Answer 3

Occurs in 10-35% of heavy drinkers

Question 4

Recognise the presenting symptoms of alcoholic hepatitis

Answer 4

May remain asymptomatic and undetected  
May be mild illness with symptoms such as: 
Nausea  
Malaise  
Epigastric pain  
Right hypochondrial pain  
Low-grade fever  

More severe presenting symptoms include:
Jaundice
Abdominal discomfort or swelling
Swollen ankles
GI bleeding
NOTE: a long history of heavy drinking is required for the development of alcoholic hepatitis (around 15-20 years)
There may be events that trigger the disease (e.g. aspiration pneumonia, injury)

Question 5

Recognise the signs of alcoholic hepatitis on physical examination

Answer 5

Signs of Alcohol Excess:
Malnourished  
Palmar erythema  
Dupuytren's contracture  
Facial telangiectasia 
Parotid enlargement  
Spider naevi
Gynaecomastia  
Testicular atrophy  
Hepatomegaly  
Easy bruising

Signs of Severe Alcoholic Hepatitis:
Febrile (in 50% of patients)  
Tachycardia  
Jaundice  
Bruising  
Encephalopathy (e.g. liver flap, drowsiness, disorientation) 
Ascites  
Hepatomegaly  
Splenomegaly

Question 6

Identify appropriate investigations for alcoholic hepatitis

Answer 6

Bloods 
FBC: 
Low Hb 
High MCV 
High WCC 
Low platelets  
LFTs: 
High AST + ALT 
High bilirubin 
High ALP + GGT 
Low albumin  
U&Es: 
Urea and K+ tend to be low  
Clotting: prolonged PT is a sensitive marker for significant liver damage 

Ultrasound - check for other causes of liver impairment (e.g. malignancy)
Upper GI Endoscopy - investigate varices
Liver Biopsy - can help distinguish from other causes of hepatitis
EEG - slow-wave activity indicates encephalopathy

Question 7

Generate a management plan for alcoholic hepatitis

Answer 7

Acute:
Thiamine
Vitamin C and other multivitamins (can be given as Pabrinex)
Monitor and correct K+, Mg2+ and glucose
Ensure adequate urine output
Treat encephalopathy with oral lactulose or phosphate enemas
Ascites - manage with diuretics (spironolactone with/without furosemide)
Therapeutic paracentesis
Glypressin and N-acetylcysteine for hepatorenal syndrome

Nutrition:
Via oral or NG feeding is important
Protein restriction should be avoided unless the patient is encephalopathic
Nutritional supplementation and vitamins (B group, thiamine and folic acid) should be started parenterally initially, and continued orally
Steroid Therapy - reduce short-term mortality for severe alcoholic hepatitis

NOTE: hepatorenal syndrome - the development of renal failure in patients with advanced chronic liver disease
Thought to arise because of abnormalities in blood vessel tone in the kidneys
Blood vessels in the kidney constrict because of the dilatation of blood vessels in the splanchnic circulation (supplying the intestines), which is mediated by factors released by the kidneys
The splanchnic vasodilation leads to reduced effective volume of blood detected by the juxtaglomerular apparatus, leading to activation of the RAS and vasoconstriction of vessels in the kidney
This leads to kidney failure

Question 8

Identify the possible complications of alcoholic hepatitis

Answer 8

Acute liver decompensation
Hepatorenal syndrome
Cirrhosis

Question 9

Summarise the prognosis for patients with alcoholic hepatitis

Answer 9

Mortality:
First month = 10%
First year = 40%
If alcohol intake continues, most will progress to cirrhosis within 1-3 years