Alcoholic Hepatitis

Question 1

Define Alcoholic Hepatitis

Answer 1

Alcoholic hepatitis = syndrome of progressive inflammatory liver injury caused by chronic heavy alcohol intake

Part of alcoholic liver disease (ALD)
Fatty liver (steatosis) -> Alcoholic steatohepatitis (inflammation and necrosis) -> Alcoholic liver cirrhosis

Question 2

What is the aetiology of alcoholic hepatitis?

Answer 2

Caused by drinking very large amounts over a long period

Alcohol metabolism = NADH -> inhibits gluconeogenesis and fatty acid oxidation -> steatohepatitis

An undefined trigger initiates a severe pro-inflammatory response associated with oxidant injury and neutrophil infiltration

Trigger event = Aspiration pneumonia, injury, bleeding, diuretics, etc.

Question 3

What is the epidemiology of alcoholic hepatitis?

Answer 3

10-35% of heavy drinkers develop alcoholic hepatitis

Question 4

What are the symptoms of alcoholic hepatitis?

Answer 4

Asymptomatic

Acute:
Headache
Nausea and vomiting

Mild:
Nausea
Malaise
RUQ/epigastric pain

Severe – liver failure:
Pruritis + jaundice
Abdominal discomfort – ascites/pain
Ascites - swelling
Peripheral oedema - swollen ankles
Coffee ground vomit - GI bleeding

Question 5

What are the signs of alcoholic hepatitis?

Answer 5

Signs of alcohol excess/chronic stable liver disease:
Palmar erythema
Dupuytren’s contracture
Spider naevi
Gynacomastasia

Signs of severe alcoholic hepatitis
Febrile (50%)
Tachycardia
Jaundice (50%)
Ascites
Asterixis
Encephalopathy
Bruising
Hepatomegaly/splenomegaly

Signs of malnutrition (B12 deficiency)
Polyneuropathy
Wernicke’s encephalopathy – ataxia, opthalmoplegia,

Question 6

What investigations would be done to diagnose alcoholic hepatitis? What would the results show?

Answer 6

Bloods
FBC: macrocytic anaemia, leukocytosis, thrombocytopenia
LFTs: increased AST, ALT, ALP, GGT, bilirubin, decreased albumin
AST:ALT ratio >2
Clotting: prolonged PT (sensitive liver damage marker)
Vitamins – malnutrition
U+Es – hyponatraemia

Question 7

What is the management of alcoholic hepatitis?

Answer 7

Acute
Treat deficiencies, parenterally
Thiamine, vit-C, vit-Bs, folic acid and multivitamins

Monitor electrolytes
K, Mg and glucose

Ensure adequate urine output

Treat encephalopathy
Oral lactulose
Phosphate enemas

Manage ascites
Diuretics: spirolactone +/- frusemide
Therapeutic paracentesis

Nutrition
Oral/NG feeding with increased caloric intake
Aim for total enteral nutrition

Steroid therapy
Reduce short term mortality in severe cases

Long term
Alcohol abstinence

Question 8

What are possible complications of alcoholic hepatitis?

Answer 8

Acute liver decompensation
Hepatorenal syndrome -> renal failure
Hepatopulmonary syndrome – pulmonary vessels dilate -> SOB, hypoxaemia

Cirrhosis -> HCC, portosystemic thrombus + haemorrhage

Question 9

What is the prognosis for alcoholic hepatitis?

Answer 9

Best prognosis with alcohol abstinence

Mortality
15% mortality if hospitalized
10% in first month, 40% in first year

Cirrhosis
In those who recover from alcoholic hepatitis, cirrhosis develops in >10% per year
Most within 1-3 years

Worse prognosis if
Hepatitis C infection
Female

Question 10

What are some prognosis scoring systems for alcoholic hepatitis?

Answer 10

Maddrey’s discriminant function
Looks at bilirubin and PT prolongation
If over 32, the 30 day mortality is >50%

Glasgow alcoholic hepatitis score
Looks at age, WCC, urea, PT ratio, bilirubin
If 9 or over from day 1-9, the 30 day mortality is >50%