#Alcoholic Hepatitis

-Maddrey's: ***, MELD-Na: ***

- currently drinking ***/week, Ethanol Level: ***

PE: hepatomegaly, jaundice, ascites, encephalopathy, fever

-f/up HIV, Hepatitis Panel (HAV IgM/IgG, HbsAg, HBV DNA, HCV Ab, HCV RNA)

-recent acetaminophen use, herbs, FamHx of liver dz

-Alk Phos:***, AST/ALT: ***

-WBC: ***, T Bili: ***, GGT: ***

-INR: ***, NH3: ***, TAG: ***

-RUQ US w/Dopplers: ***

Clinical Dx for alcoholic hepatitis:

-Onset of jaundice within prior 8 weeks

-AST to ALT ratio > 1.5( and both values <400 international units/L)

-Serum total bilirubin > 3 mg/dL

-Alcohol consumption >40g (females) or 60g (males) /day for at least 6 months, with < 60 days of abstinence before the onset of jaundice.

Prior to initiating corticosteroid therapy:

- Systematically screen for active infection before initiating steroids, during corticosteroid treatment, and during follow-up period (EASL Grade A, Level 1)

- Assess for other contraindications to corticosteroids, including:

  1. acute kidney injury with serum creatinine > 2.5 mg/dL

2. uncontrolled upper gastrointestinal bleed

3. drug-induced liver disease

4. hepatocellular carcinoma

5. acute pancreatitis

6. multiorgan failure or shock

7. infections such as hepatitis B or C virus, HIV, or tuberculosis

Plan:

- Screen for infection with chest x-ray and blood, urine, and ascites cultures

- Rule out other causes of jaundice with abdominal ultrasound:

- HIV, tuberculosis, HCV AB and RNA, HepB labs: HCV DNA, HepBsAg, HepBsAb, HepBcAb, HepBeAg, HepBeAb

***If MELD >20 or MDF>or =32 consider Initiation of prednisolone 40mg/day with or without IV N-acetylcysteine x 7 days, taper over 2 weeks.

- Calculate Lille Score and f/up score on day 7.

- If score < 0.45, continue treatment for 4 weeks and taper over ≥ 2 weeks, then continue supportive management

- If score ≥ 0.45, stop therapy and consider alternatives

**** if patient is not eligible for steroids consider referral for early liver transplantation

***follow-up Phos, Mg for refeeding syndrome

- Alcohol withdrawal protocol, low dose

- Daily multivitamin, folic acid, thiamine

References:

Crabb DW, Im GY, Szabo G, Mellinger JL, Lucey MR. Diagnosis and Treatment of Alcohol-Associated Liver Diseases: 2019 Practice Guidance From the American Association for the Study of Liver Diseases. Hepatology. 2020 Jan;71(1):306-333. doi: 10.1002/hep.30866. PMID: 31314133.