🍷 Alcohol is a leading cause of liver disease worldwide. Among its spectrum, alcoholic hepatitis (AH) is a distinct clinical syndrome marked by acute hepatic inflammation in heavy drinkers, often superimposed on chronic liver disease. ⚠️ Mortality can reach 30–40% at 1 month in severe cases.

⚙️ Pathophysiology

Excess ethanol metabolism → NAD⁺ depletion, oxidative stress, acetaldehyde toxicity.
Triggers inflammation: neutrophil infiltration, cytokine release (TNF-α, IL-8).
Histology 🔬: hepatocyte ballooning, Mallory–Denk bodies, neutrophilic lobular infiltrates, pericentral fibrosis.
Progression: steatosis → alcoholic hepatitis → cirrhosis.

🩺 Clinical Features

Recent jaundice (within weeks).
RUQ pain, tender hepatomegaly.
Fever, malaise, anorexia, weight loss.
Stigmata of chronic liver disease (spider naevi, ascites, encephalopathy).
Often triggered by binge or continued heavy drinking after cirrhosis develops.

🔬 Investigations

LFTs: AST:ALT ratio >2 (enzymes rarely >300 IU/L).
Bilirubin: often >80–100 μmol/L.
FBC: ↑MCV, anaemia, neutrophilia.
Clotting: ↑INR/PT – key prognostic marker.
Scoring systems:
- 🧮 Maddrey’s Discriminant Function (DF) ≥32 → severe disease.
- MELD score, Glasgow Alcoholic Hepatitis Score (GAHS) also used.
Imaging: US liver to exclude obstruction, cirrhosis, HCC.
Liver biopsy only if diagnosis uncertain and will alter management.

⚠️ Complications

Hepatic encephalopathy 🧠
Variceal bleeding 💉
Sepsis & spontaneous bacterial peritonitis 🦠
Renal failure (hepatorenal syndrome) 💧
Progression to cirrhosis & HCC

💊 Management

General:
- 🚫 Strict alcohol abstinence.
- Nutrition: high-protein, high-calorie diet; vitamin (esp. thiamine) supplementation.
Specific:
- Prednisolone 40 mg/day × 28 days if DF ≥32 and no sepsis, GI bleed, or renal failure.
- Pentoxifylline (less used now; alternative if steroids contraindicated).
- Lille score at day 7 → guides continuation of steroids (non-responders have poor prognosis).
Supportive:
- Treat infections aggressively.
- Ascites → diuretics, paracentesis + albumin.
- Encephalopathy → lactulose, rifaximin.
- HRS → terlipressin + albumin.
Definitive: Liver transplant in select abstinent patients.

📈 Prognosis

Mild disease: recovery possible with abstinence.
Severe AH (DF ≥32): 30–40% 28-day mortality.
Ongoing drinking → 50% mortality at 5 years.

🧠 Clinical Pearl

🌟 Any patient with new jaundice, fever, RUQ pain and heavy alcohol use → suspect alcoholic hepatitis. Always calculate a prognostic score (DF, MELD, GAHS) to guide steroid therapy. Never forget nutritional support – malnutrition is a major cause of death.

📊 Spectrum of Alcohol-Related Liver Disease

Feature	🍔 Fatty Liver (Steatosis)	🔥 Alcoholic Hepatitis	⚖️ Cirrhosis
Pathology	Fat accumulation in hepatocytes	Inflammation + hepatocyte necrosis, Mallory bodies	Fibrosis + regenerative nodules → irreversible
Clinical Features	Often asymptomatic, mild RUQ discomfort, hepatomegaly	Acute jaundice, fever, RUQ pain, tender hepatomegaly	Ascites, varices, encephalopathy, stigmata of CLD
LFTs	Mild ↑ ALT/AST, usually <100	AST:ALT >2, both <300; ↑ bilirubin, ↑ INR	Variable; decompensated: ↑ bilirubin, ↓ albumin, ↑ INR
Prognosis	Reversible with abstinence ✅	30–40% 1-month mortality if severe ❌	Progressive, irreversible; transplant may be required ⚠️
Management	Alcohol abstinence, lifestyle, monitor	Abstinence, nutrition, steroids if severe (DF ≥32)	Abstinence, manage complications, consider transplant

🔗 References

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Alcoholic Hepatitis