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Alcoholic hepatitis typically occurs after more than 10 years of regular heavy alcohol use; patients typically present with recent onset of jaundice (left), ascites, and proximal muscle loss.
Case
A 53-year-old man with a history of daily alcohol use presents with one week of jaundice. His blood pressure is 95/60 mmHg, pulse 105/minute, and temperature 38.0°C. Examination discloses icterus, ascites, and an enlarged, tender liver. His bilirubin is 9 mg/dl, AST 250 IU/dL, ALT 115 IU/dL, prothromin time 22 seconds, INR 2.7, creatinine 0.9 mg/dL, and leukocyte count 15,000/cu mm with 70% neutrophils. He is admitted with a diagnosis of acute alcoholic hepatitis. How should he be treated?
Background
Hospitalists frequently encounter patients who use alcohol and have abnormal liver tests. Regular, heavy alcohol consumption is associated with a variety of forms of liver disease, including fatty liver, inflammation, hepatic fibrosis, and cirrhosis. The term “alcoholic hepatitis” describes a more severe form of alcohol-related liver disease associated with significant short-term mortality.
Alcoholic hepatitis typically occurs after more than 10 years of regular heavy alcohol use; average consumption in one study was 100 g/day (the equivalent of 10 drinks per day).1 The typical patient presents with recent onset of jaundice, ascites, and proximal muscle loss. Fever and leukocytosis also are common but should prompt an evaluation for infection, especially spontaneous bacterial peritonitis. Liver biopsy in these patients shows steatosis, swollen hepatocytes containing eosinophilic inclusion (Mallory) bodies, and a prominent neutrophilic inflammatory cell infiltrate. Because of the accuracy of clinical diagnosis, biopsy is rarely required, relying instead on clinical and laboratory features for diagnosis (see Table 1, below).
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Table 1. Typical clinical and laboratory features of alcoholic hepatitis
Prognosis can be determined with prediction models. The most common are Model for End-Stage Liver Disease (MELD) and Maddrey’s discriminate score (see Table 2). Several websites allow quick calculation of these scores and provide estimated 30-day or 90-day mortality. These scores can be used to guide therapy.
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Table 2. Common scoring systems used to predict prognosis in alcoholic hepatitis
Review of the Data
How should hospitalists treat this serious illness? The evidence-based literature supporting the efficacy of treatments for alcoholic hepatitis is limited, and expert opinions sometimes conflict.
Abstinence has been shown to improve survival in all stages of alcohol-related liver disease.2 This can be accomplished by admitting this patient population to the hospital. A number of interventions and therapies are available to increase the chance of continued abstinence following discharge (see Table 3).
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Table 3. Treatment considerations in alcoholic hepatitis
Nutritional support. Protein-calorie malnutrition is seen in up to 90% of patients with cirrhosis.3 The cause of malnutrition in these patients includes decreased caloric intake, metabolic derangements that accompany liver disease, and micronutrient and vitamin deficiencies. Many of these patients rely almost solely on alcohol for caloric intake; this contributes to potassium depletion, which is frequently seen. After admission, these patients are often evaluated for other conditions (such as gastrointestinal bleeding and altered mental status) that require them to be NPO overnight, thus further confounding their malnutrition. Enteral nutritional support was shown in a multicenter study to be associated with reduced infectious complications and improved one-year mortality.4