Alcohol-induced hepatitis: Clinical sciences

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Introduction0:00–0:56

Alcohol-induced hepatitis, or simply alcoholic hepatitis, refers to acute liver inflammation caused by recent excessive alcohol intake, that presents with jaundice and elevated liver enzymes.
Prolonged alcohol intake can result in lipid infiltration and increased production of free oxygen species. Over time, this can lead to inflammation and neutrophilic infiltration of hepatocytes that can eventually lead to fibrosis, cirrhosis, and liver failure.
As hepatocytes degenerate, they release intracellular enzymes, such as alanine aminotransferase or ALT, aspartate aminotransferase or AST, and gamma glutamyl transferase or GGT.Now, if you suspect alcohol-Induced hepatitis, first you should perform an ABCDE assessment to determine if the patient is unstable or stable.

Unstable patient0:56–1:25

If your patient is unstable, stabilize their airway, breathing, and circulation. Next, obtain IV access and put your patient on continuous vital sign monitoring, including blood pressure, heart rate, and pulse oximetry.
Ok, now let’s go back to the ABCDE assessment and take a look at stable individuals. If the patient is stable, proceed with a focused history and physical exam.

Stable patient1:25–4:16

Ask your patient specifically about their recent alcohol consumption. Your patient may report heavy drinking, consuming 3 or more drinks per day, usually for a minimum of 6 months.
If your patient is hesitant to discuss their alcohol use habits, you could use clinical tools, such as the AUDIT and CAGE questionnaires, which can help you identify harmful drinking patterns.
Additionally, your patient might report right upper quadrant pain, nausea, and vomiting. In advanced cases, history might also reveal easy bruising and unintended weight loss.
On the other hand, physical exam often reveals jaundice, right upper quadrant tenderness, hepatomegaly, and splenomegaly.
In advanced cases you might see ascites, primarily due to portal hypertension, but also asterixis, agitation, and confusion.At this point, you should suspect alcohol-induced hepatitis, so your next step is to order labs, such as AST, ALT, GGT, as well as total bilirubin and coagulation studies, primarily INR.
Lab results that support the diagnosis of alcohol-induced hepatitis include elevations of AST and ALT usually around 2 times the upper limit of normal, and an AST/ALT ratio higher than 1.5 is highly suggestive of alcoholic liver injury, and sometimes the ratio is even higher than 2.
Keep in mind that a normal ratio should be lower than 1. Additionally, GGT and total bilirubin are also elevated, as is the INR to a value of 1.5 or more.
Okay, these lab results in combination with your previous history and physical findings strongly support the diagnosis of alcohol-induced hepatitis.
However, some patients can also have variable laboratory findings that are not supportive of the diagnosis. In this case, if your clinical suspicion is still high, you should order a transjugular liver biopsy to confirm or rule out the diagnosis of alcohol-induced hepatitis.
If the biopsy shows confirmatory findings like macrovesicular steatosis in a centrilobular pattern, this strongly supports the diagnosis of alcohol-induced hepatitis.
On the other hand, non-confirmatory findings should lead you to consider an alternative diagnosis. Okay, once you diagnose alcohol-induced hepatitis, you need to calculate the disease severity.

MELD/MDF score4:16–7:34

This can be done by using validated metrics, such as the model for end-stage liver disease, or MELD score, and Maddrey discriminant function, or MDF score.
To calculate a MELD score you’ll need your patient’s creatinine, total bilirubin, INR, and sodium levels; while the MDF only requires the patient’s prothrombin time and total bilirubin.
These scores help to estimate the patient’s prognosis and guide management decisions. A MELD score less than or equal to 20 and MDF score less than or equal to 32 indicates mild to moderate alcohol-induced hepatitis.
These patients can be treated with outpatient management, which primarily relies on lifestyle modifications, like abstinence from alcohol; and medications, like Naltrexone, which can help reduce cravings.
You should provide education on alcohol cessation support, such as one-on-one counseling, outpatient alcohol rehabilitation programs, and group support organizations.Now let’s return to the MELD and MDF scores and discuss patients with a MELD score greater than 20 or MDF score greater than 32.
These patients have a more advanced liver injury and require inpatient management. First, administer IV methylprednisolone to address hepatic inflammation.
Alternatively, if glucocorticoids are contraindicated, like in patients with high risk of GI bleed or uncontrolled diabetes or infection, treat inflammation with pentoxifylline.
Additionally, start alcohol detoxification treatment including IV nutritional supplementation with thiamine, folate, pyridoxine, magnesium, and potassium.
Next, to reduce withdrawal symptoms, give benzodiazepines, like lorazepam and oxazepam. Continue these measures for 5-7 days and if your patient fails to improve, consider liver transplant, especially if their MELD score remains above 26.
Now, here’s a high yield fact to keep in mind! Regardless of the MELD and MDF scores, patients with alcohol-induced hepatitis are at risk for alcohol withdrawal syndrome, which can manifest with seizures, alcoholic hallucinosis, and delirium tremens.
Withdrawal seizures are typically generalized tonic-clonic seizures that occur within 1 to 2 days after the last drink. Alcoholic hallucinosis involves hallucinations, most often visual, that develop within 1 to 2 days after the last drink and typically resolve within 2 days.
Lastly, delirium tremens is the most severe a potentially fatal manifestation of alcohol withdrawal, presenting with extreme hypertension, tremors, seizures, disorientation, and hallucinations that typically occur during the first 2 to 4 days after your patient’s last drink and may last 1 to 5 days.
Alright, as a quick recap… If you suspect alcohol-induced hepatitis, first do an ABCDE assessment to determine if the patient is unstable or stable.

Review7:34–9:11

If unstable, stabilize the airway, breathing, and circulation; obtain IV access; and put your patient on continuous vital sign monitoring.
On the other hand, if stable, order labs such as AST, ALT, GGT, total bilirubin, and INR. Lab results that support the diagnosis include elevations of AST and ALT usually around 2 times the upper limit of normal with an AST/ALT ratio higher than 1.5.
On the other hand, if labs reveal non-supportive findings, but you still have a high level of clinical suspicion, proceed with transjugular liver biopsy.
Biopsy findings that reveal macrovesicular steatosis in a centrilobular pattern are highly suggestive of alcohol-induced hepatitis.
Now, once you’ve diagnosed alcohol induced hepatitis, calculate MELD and MDF scores. If MELD is 20 or less and MDF is 32 or less, recommend outpatient treatment with lifestyle modifications; medications, like Naltrexone; and alcohol cessation support.
However, if the MELD score is greater than 20 and MDF score is greater than 32, admit your patient to the hospital, start methylprednisolone or pentoxifylline, and begin with alcohol detoxification treatment.
Finally, keep in mind that some patients might require liver