Makindo Medical Notes

🍷 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

🔗 References

• NICE: Alcohol-use disorders
• EASL 2020 Guidelines on Alcohol-related Liver Disease