The document discusses alcoholic hepatitis, including its clinical presentation, diagnostic testing, and management. It reviews that alcoholic hepatitis typically presents with jaundice, anorexia, fever, abdominal pain, and sometimes encephalopathy in patients with a history of heavy alcohol use over 100g per day. Diagnostic testing includes liver function tests showing elevated AST and ALT with an AST:ALT ratio over 2, as well as elevated bilirubin and INR. Management involves alcohol abstinence, treatment of withdrawal if needed, nutritional support, and steroids or supportive care depending on disease severity. The most common cause of acute liver failure is alcoholic hepatitis.

1. Noon Conference
Christina Lieu
02/21/2019

2. © 2016 Virginia Mason Medical Center
Objectives
Alcoholic hepatitis
• Review clinical presentation
• Discuss diagnostic testing
• Discuss management
• Review illness script
2

3. © 2016 Virginia Mason Medical Center
Alcoholic liver disease
• Alcoholic steatosis
• Alcoholic hepatitis
• Alcoholic cirrhosis
3

4. © 2016 Virginia Mason Medical Center
Clinical presentation
• History of heavy alcohol use (>100g
per day)
• Symptoms
• Jaundice
• Anorexia
• Fever
• RUQ/epigastric pain
• Proximal muscle weakness/wasting
• Ascites
• Hepatic encephalopathy
4

5. © 2016 Virginia Mason Medical Center
Hepatic encephalopathy
Grade Mental Status Asterixis EEG
I Euphoria/depression
Mild confusion
Disordered sleep
Yes/no Usually normal
II Lethargy
Moderate confusion
Yes Abnormal
III Marked confusion
Incoherent
Sleeping but arousable
Yes Abnormal
IV Coma
Unresponsive to pain
Absent Abnormal
5

6. © 2016 Virginia Mason Medical Center
Lab findings
• Elevated AST and ALT
• AST:ALT ratio >2
• Elevated serum bilirubin
• Leukocytosis with neutrophilic
predominance
• Elevated INR
• Low albumin
6

7. © 2016 Virginia Mason Medical Center
Diagnosis
• History of heavy alcohol use, clinical
presentation, and lab findings
• Other testing:
• HAV IgM
• HBsAg, HBsAb, HBcAg
• HCV antibodies, HCV RNA
• Abdominal US
• Liver biopsy
7

8. © 2016 Virginia Mason Medical Center 8

9. © 2016 Virginia Mason Medical Center
Question
What is the most common cause of
acute liver failure?
a) Alcoholic hepatitis
b) Acetaminophen toxicity
c) Viral hepatitis
d) Idiosyncratic drug reaction
9

10. © 2016 Virginia Mason Medical Center
Question
What is the most common cause of
acute liver failure?
a) Alcoholic hepatitis
b) Acetaminophen toxicity
c) Viral hepatitis
d) Idiosyncratic drug reaction
10

11. © 2016 Virginia Mason Medical Center
Determining disease severity
Maddrey discriminant function
DF = 4.6 x [PT – control PT] + bilirubin
DF <32 = mild/moderate disease
DF >32 = severe disease
MELD score
11

12. © 2016 Virginia Mason Medical Center
MKSAP Question
55 y/o man is hospitalized for a 2-week history of jaundice and AMS. He has a
10-year history of alcohol dependence. His family reports that he had been
drinking heavily every day until about 3 weeks ago.
On exam, the patient is confused and lethargic. T 100.0 F, BP 90/60, P 120,
RR 30. Exam reveals scleral icterus. There is no guarding on palpation of the
abdomen. The liver edge is tender and easily palpable 3 cm below the right
costal margin. There is no ascites, edema, or evidence of bleeding.
Labs show WBC 17k, platelets 103k, PT 26.2, INR 4.0, bilirubin 37, AST 98,
ALT 50, ALP 230, albumin 2.0, ammonia 110.
Which of the following is the most appropriate management for this patient?
A. Ceftriaxone
B. Methylprednisolone
C. Supportive care
D. Liver transplantation
12

13. © 2016 Virginia Mason Medical Center
MKSAP Question
55 y/o man is hospitalized for a 2-week history of jaundice and AMS. He has a
10-year history of alcohol dependence. His family reports that he had been
drinking heavily every day until about 3 weeks ago.
On exam, the patient is confused and lethargic. T 100.0 F, BP 90/60, P 120,
RR 30. Exam reveals scleral icterus. There is no guarding on palpation of the
abdomen. The liver edge is tender and easily palpable 3 cm below the right
costal margin. There is no ascites, edema, or evidence of bleeding.
Labs show WBC 17k, platelets 103k, PT 26.2, INR 4.0, bilirubin 37, AST 98,
ALT 50, ALP 230, albumin 2.0, ammonia 110.
Which of the following is the most appropriate management for this patient?
A. Ceftriaxone
B. Methylprednisolone
C. Supportive care
D. Liver transplantation
13

14. © 2016 Virginia Mason Medical Center
Management
• Alcohol abstinence
• Treatment of alcohol withdrawal
• Nutritional support, vitamin repletion
• Fluid management
• Discontinue nonselective beta
blockers
• Management of complications of
cirrhosis
14

15. © 2016 Virginia Mason Medical Center
Management
• Mild/moderate disease: supportive
care
• Severe disease:
• Steroids
• Pentoxifylline
• Lille score
• >0.45 = steroid nonresponder
• Liver transplantation
15

16. © 2016 Virginia Mason Medical Center
Illness Scripts
16
Alcoholic hepatitis Acute viral hepatitis
Pathophysiology Alcohol toxicity HAV, HBV infection
Epidemiology
40-60 y/o
History of excessive alcohol use
Travel to endemic areas
Vertical transmission in high prevalence areas
Sexual transmission/IVDU in lower prevalence
areas
Time course Acute on chronic Acute/subacute
Clinical
presentation
Jaundice, anorexia, RUQ pain, fever,
encephalopathy, ascites, proximal muscle
wasting
Constitutional symptoms, jaundice, anorexia,
RUQ pain, encephalopathy
Diagnostics
Labs: AST and ALT elevated to 300-500,
AST:ALT >2, leukocytosis, elevated bilirubin,
elevated INR, low albumin
Abdominal imaging: fatty liver, cirrhosis, ascites
Liver biopsy: steatosis, Mallory-Denk bodies,
neutrophilic infiltration
Labs: AST and ALT elevated to 1000-2000,
ALT>AST, elevated bilirubin, elevated INR
HBsAg and HBcAg positive
Therapeutics Prednisolone vs. supportive care Tenofovir, entecavir vs. supportive care