Alcoholic Hepatitis

Question 1

Define Alcoholic Hepatitis

Answer 1

Inflammatory liver injury caused by the chronic heavy intake of alcohol

Stage 2 of alcoholic liver disease (fatty liver/steatosis -> alcoholic hepatitis -> cirrhosis)

Question 2

Aetiology of alcoholic hepatitis

Answer 2

Alcohol metabolism in the liver produces excess NADH -> inhibits gluconeogenesis and fatty acid oxidation
Hepatocyte damage, inflammation + fibrosis + collagen surrounding hepatocytes + fatty changes

Question 3

Symptoms of alcohol hepatitis

Answer 3

May be asymptomatic and undetected

Illness
Nausea
Malaise 
Epigastric of right hypochondriac pain 
Low grade fever 

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

History of heavy alcohol intake (10-15 years)

Question 4

Signs of alcoholic hepatitis

Answer 4

Alcohol excess: malnourished | palmar erythema | Dupytren’s contracture | facial telangiectasia | parotid enlargement | spider naevi | gynaecomastia | testicular atrophy | hepatomegaly | bruising

Severe:
Febrile
Tachycardia 
Jaundice
Drowsiness - unable to copy a 5 point star, disorientated
Ascites
Hepatosplenomegaly

Question 5

Investigations for alcoholic hepatitis

Answer 5

Liver biopsy: histology of alcoholic hepatitis

LFTs: ALT and AST raised (AST:ALT ratio >2), GGT, bilirubin raised, albumin reduced , alk phos raised
PT: prolonged or normal
FBC: macrocyclic anaemia, WCC raised, platelets reduced
U+Es: urea and K levels tend to be low

USS: normal, may show hepatomegaly, fatty liver, cirrhosis, a mass, spleen omega lay,ascites, portal HTN (rule out other causes of liver enlargement)
Electroencephalogram: slow waves in encephalopathy

Question 6

What is the histology of alcoholic hepatitis found on biopsy

Answer 6

Hepatocyte damage: 
Centrilobular balloon cells
Mallory hyaline inclusions 
Neutrophils and lymphocytes 
Giant mitochondria
Necrosis of hepatocytes
Steatosis 
Chlolestasis 
Collagen-surrounded hepatocytes 
Fibrosis

Question 7

Management for acute presentation of alcoholic hepatitis

Answer 7

Thiamine (pabrinex)
Parenteral vitamins e.g. vit C
Correct electrolyte abnormalities
Diuretics (spironolactone ± furosemide) or therapeutic parachutes is
Alcohol withdrawal management - benzodiazepines
Nutritional support + supplementation (thiamine, vit B, folic acid,)

Encephalopathy: oral lactulose + phosphate enema

Question 8

Long term management for alcoholic hepatitis

Answer 8

Advise drinking cessation
Supportive care: abstinence counselling, interventions, AAA, rehab 
Smoking cessation
Weight reduction
Influenza and pneumococcal vaccination

Question 9

Complications of alcohol hepatitis

Answer 9

Untreated -> CLD and liver cirrhosis -> liver failure

Question 10

Prognosis for alcoholic hepatitis

Answer 10

Mortality in the first month is 10%, first year 40%
Progression to cirrhosis within 1-2 years
Prognostic scores: Maddrey’s discrimination function (MDF) | Glasgow alcoholic hepatitis score (GAHS)