Alcoholic hepatitis

Overview

Alcoholic hepatitis is an acute inflammatory liver syndrome from heavy alcohol use - distinct from steatosis and cirrhosis but can coexist. Severe disease carries 28-day mortality of 30-50%.

Presentation

•Jaundice - rapid onset (days to weeks); impaired bilirubin conjugation

•RUQ pain/tenderness and hepatomegaly - tender, enlarged liver

•Fever - sterile, cytokine-driven (TNF-alpha, IL-6); must exclude infection first

•Hepatic encephalopathy - confusion, asterixis; marker of severe disease

•Ascites, splenomegaly - portal hypertension, especially if cirrhosis coexists

•Coagulopathy - bruising, prolonged PT; impaired clotting factor synthesis

⚠️
Fever in alcoholic hepatitis is a diagnosis of exclusion - always rule out SBP, pneumonia, and UTI before attributing fever to hepatitis alone. Infection is a common precipitant AND complication.

Investigations

•LFTs - AST:ALT ratio >2:1 (biochemical fingerprint); AST rarely >300-500 IU/L; raised bilirubin; low albumin

•FBC - macrocytosis (MCV >100 fL), anaemia; raised WBC

•PT/INR - prolonged; used in Maddrey's Discriminant Function (MDF) calculation

•U&Es/creatinine - assess for hepatorenal syndrome

•Glucose - hypoglycaemia risk from impaired gluconeogenesis

•HBsAg, hepatitis C antibody - exclude concurrent viral hepatitis

•Abdominal USS - liver size/echogenicity, excludes biliary obstruction, identifies ascites

•Blood/urine cultures, ascitic tap - exclude infection before attributing fever

🏆 Gold standard

•liver biopsy (transjugular if coagulopathic) - reserved for diagnostic uncertainty

💡
AST:ALT >2:1 occurs because alcohol depletes pyridoxal phosphate (vitamin B6), suppressing ALT synthesis disproportionately, and AST is also released from alcohol-damaged mitochondria. If AST >500 IU/L, consider an alternative diagnosis (paracetamol toxicity, ischaemic hepatitis, viral hepatitis).

Management

All patients
1Complete abstinence from alcohol - cornerstone of management
2Aggressive nutritional support - enteral feeding if required
3IV thiamine (Pabrinex) - prevent/treat Wernicke's encephalopathy
4Alcohol withdrawal protocol - chlordiazepoxide
5Refer to specialist alcohol liaison team
6Exclude and treat infection before starting corticosteroids
↓
Mild-moderate (MDF <32)
Supportive care, abstinence, nutritional support - no steroids indicated
Severe (MDF ≥32), no contraindication
Prednisolone 40 mg daily - assess response with Lille score at day 7
↓
Day 7 - Lille score
1Lille score >0.45 = non-responder - stop prednisolone; no benefit from continuation; poor prognosis
2Lille score ≤0.45 = responder - continue prednisolone for 28 days

📌
Liver transplantation may be considered in highly selected patients with severe alcoholic hepatitis who fail medical treatment - most UK centres require 6 months of abstinence before listing.

Complications

•Hepatorenal syndrome (HRS) - functional AKI; type 1 progresses rapidly and is life-threatening

•Spontaneous bacterial peritonitis (SBP) - diagnose by ascitic PMN count >250 cells/mm³

•Hepatic encephalopathy - precipitated by infection, GI bleeding, constipation, certain medications

•Variceal haemorrhage - oesophageal/gastric varices from portal hypertension

•Wernicke's encephalopathy - thiamine deficiency; confusion, ophthalmoplegia, ataxia; actively prevent with IV thiamine

•Progression to cirrhosis - up to 40% within 5 years if drinking continues

•Hepatocellular carcinoma (HCC) - long-term complication of cirrhosis; 6-monthly USS ± AFP surveillance

Prognosis

•Severe disease (MDF ≥32) - 28-day mortality 30-50% without treatment

•Lille score >0.45 at day 7 - indicates non-response to corticosteroids; particularly poor prognosis

•Abstinence - single most important determinant of long-term survival; meaningful histological improvement possible even from advanced fibrosis

Severity scoring

Maddrey's Discriminant Function (MDF) vs Glasgow Alcoholic Hepatitis Score (GAHS)
FeatureMDFGAHS
Severe threshold≥32≥9
Clinical useMost widely used; guides steroid decisionUsed alongside MDF in UK practice
Implication of severe scoreConsider prednisolone if no contraindicationConsider prednisolone if no contraindication

Feature	MDF	GAHS
Severe threshold	≥32	≥9
Clinical use	Most widely used; guides steroid decision	Used alongside MDF in UK practice
Implication of severe score	Consider prednisolone if no contraindication	Consider prednisolone if no contraindication