Alcoholic hepatitis

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Alcoholic hepatitis
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How is Alcoholic hepatitis diagnosed?

• History of recent excessive alcohol ingestion
• Serum bilirubin more than 80umol/l
• ALT lt300 IU (or ASTlt500 IU)
• Exclusion of autoimmune, chronic viral or
  malignant liver disease

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Characteristic features of alcoholic hepatitis
(but not necessary for diagnosis)

• Pyrexia,
• Hepatomegaly,
• A hepatic bruit,
• Ascites,
• Encephalopathy,
• AST ALT ratio greater than 1.5,
• Peripheral leucocytosis.

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How accurate is a clinical diagnosis of Alcoholic
hepatitis?

• An accuracy of about 80 has been quoted for the
  clinical diagnosis of alcoholic hepatitis when
  compared with histology.

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Does alcoholic hepatitis with co-existing
cirrhosis alters the prognosis or treatment?
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• Approximately 50-60 will also have established
  cirrhosis.
• There is no evidence that co-existing cirrhosis
  worsens the short term outcome of patients with
  alcoholic hepatitis, indicating that it is the
  acute inflammatory process which is primarily
  responsible for the poor prognosis of these
  patients.

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How do you assess the severity of Alcoholic
Hepatitis?
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• Modified discriminant function (mDF)
• Glasgow alcoholic hepatitis score (GAHS)

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• mDF 4.6 (PTpatientPTcontrol) serum bilirubin
  (µmol/l)/17.1

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• American College of Gastroenterology defines
  severity as a modified Discriminant Function
  (mDF)gt 32 and/or hepatic encephalopathy.

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• Where would you use steroids?

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• American College of Gastroenterology recommends
  prednisolone should be used in patients with
  severe alcoholic hepatitis in whom the diagnosis
  is certain. Severity is defined as a DFgt 32
  and/or hepatic encephalopathy

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• mDFgt 32 and/or hepatic encephalopathy was
  associated with a 65 28-day survival
• lt32 had a survival of 93.

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• Patients with mDF gt32 and treated with steroids
  had a 28 day survival of 84.6 compared with
  65.1 for placebo treated patients.

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• The efficacy of steroids has not been adequately
  evaluated in patients with severe alcoholic
  hepatitis who also have
• concomitant pancreatitis,
• gastrointestinal bleeding,
• renal failure
• active infection.

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What is the steroid dose and duration?

• Prednisolone 40 mg daily for four weeks followed
  by a taper.
• Careful monitoring for evidence of infection,
  gastrointestinal bleeding, glucose intolerance,
  or renal failure is essential while the patient
  is on prednisolone therapy.

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How do you assess response?

• Any fall in serum bilirubin after one week of
  corticosteroid treatment is indicative of
  treatment response and good prognosis.

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• What other supportive care can patients with
  Alcoholic hepatitis be provided?

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• These patients are at risk of sepsis. Close
  vigilance for sepsis and a low threshold for the
  use of antibiotics is required.
• These patients have significant protein energy
  malnutrition. Nutritional support is vital for
  these patients.

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• What is GAHS?

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Criticism of mDF

• mDF relies on the absolute value of the PT
• The presence of encephalopathy has often been
  included when making a treatment decision, in
  addition to just calculating the mDF.
• mDF was highly sensitive in the prediction of
  death from alcoholic hepatitis but lacked
  specificity. This was dramatic as it incorrectly
  predicted the outcome at 28 days after admission
  in 51 of cases.
• They also suggests that even with a mDF greater
  than or equal to 32, patients with a GAHS less
  than nine do not benefit from such treatment.

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• Are there any other treatments for Alcoholic
  Hepatitis?

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• Pentoxifylline, a phosphodiesterase inhibitor
• It acts by inhibiting TNF alpha.
• Dose 400mg tds

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• One hundred one patients with severe alcoholic
  hepatitis (Maddrey discriminant factor gt or 32)
  entered a 4-week double-blind randomized trial of
  PTX (400 mg orally 3 times daily) vs. placebo
• Akriviadis E, Botla R, Briggs W, Han S, Reynolds
  T, Shakil O (2000). "Pentoxifylline improves
  short-term survival in severe acute alcoholic
  hepatitis a double-blind, placebo-controlled
  trial". Gastroenterology 119 (6) 163748

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• Twelve (24.5) of the 49 patients who received
  PTX and 24 (46.1) of the 52 patients who
  received placebo died during the index
  hospitalization (P 0.037 relative risk, 0.59
  95 confidence interval, 0.35-0.97).

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Summary

• Non cirrhotic vs cirrhotic
• Typical blood test
• Assess severity
• Treatment with steroid and pentoxyphylline
• Nutrition and alcohol detox