Alcohol-induced hepatitis: Clinical sciences

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. 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. 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.