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Today, we will be talking about Alcohol-associated hepatitis aka Alc Hep for short. Let’s talk first about diagnosis. How do you diagnose alcoholic hepatitis? And why is this important?
Diagnosis is usually made by clinical history and lab values. So there is no single test that can confirm the diagnosis of Alc hep.
A history might include: 10+ years of drinking, with an increase over the last 3-6 months, and symptoms of anorexia, malaise, jaundice.
What are the lab values you would see? – moderately elevated AST, ALT, and an AST/ALT ratio of greater than 1.5-2, typically less than 3, and a Total Bili >3 (required for the diagnosis).
Why can the presentation of alc hep be delayed up to 8 weeks from the last drink?
Well, alcohol-associated hepatitis is a multifactorial reaction that is actually immune-mediated. First, there is an initial insult to the liver by alcohol, which leads to the recruitment of inflammatory cells. It disrupts the gut barrier, leading to bacterial translocation and inflammation. Ultimately, this is why the symptoms are delayed from heavy drinking to presentation.
Let’s talk risk factors. Who is more likely to get alcohol-associated hepatitis?
Biological females, because of the lower amount of gastric alcohol dehydrogenase. Patients who smoke, those with metabolic syndrome, and a history of gastric bypass. There is also a genetic component to the disease!
When working up a patient with symptoms that seem like alcohol associated hepatitis, what else might we think about ordering or think about in our differential? We should be thinking about infection, so be sure to send of hepatitis serologies. Additionally, we should consider medications, so send a serum acetaminophen and finall,y biliary obstruction should also be on the differential. There are far more differentials to include, but always come back to the patient demographics and recent medications they’ve taken.
The most important thing to remember in caring for these patients is that they are quite prone to infections, and a large portion die from infection. So don’t forget to order blood cultures, urine cultures, and CXR. In alc hep specifically you should also send off peritoneal fluid studies, and don’t forget the physical exam. Look inside of their mouth, look at their sacrum, look at their IV sites, and other possible sources of infeciton!
Infection is also important to rule out before considering another treatment option: steroids.
When do we use steroids in alc hep?
Let’s first talk about risk stratification. The MELD score and Maddrey Discriminate Function are two scoring methods to risk-stratify those with Alcohol-Associated Hepatitis. For mild hepatitis, this can be treated conservatively. So we are are talking about those with MELD <20 or MDF <32. For those with MELD >20 or MDF >32, consider treatment with steroids, which would be a 28-day course followed by a taper. A few key points to remember with steroids: 1. There is no urgency to starting steroids, so you don’t have to rush to start them as soon as you admit your patient. 2. Make sure you rule out infection first before you start steroids. 3. There is no long-term mortality benefit to steroids. You may find these are used as a last resort and each hepatologist has a different approach of when they reach for steroids.
Next, what are the interventions most likely to improve mortality for alcohol-associated hepatitis?
These include Alcohol cessation and nutrition.
After an episode of alcohol associated hepatitis, abstinence from alcohol positively impacts long-term survival- it can reduce mortality risk by close to 50% !
During hospitalization is a good opportunity to discuss abstinence, and a recent study of 35,000 patients with ALD found that less than 2% were started on medical therapy for AUD. hmmm.
Correcting nutritional deficiencies is also important. Some studies have shown that 100% of patients with alcohol associated liver disease have some form of malnutrition. Some general guidelines are that nutrition should be provided orally if possible, or enterally if not meeting caloric needs. Supplement with thiamine, folate, and multivitamin! In certain cases, Vitamin K may be needed as well. Consider avoiding maintenance fluid to avoid fluid retention. And monitor for refeeding. Overall, we should be targeting 30 calories/kg per day with 1-1.5kg /protein!
We covered a lot here, but hope you learned some things about alcohol-associated hepatitis! Listen to our full episode with awesome guest Dr. Eliot Taper to really cement those clinical pearls!