ZSFG AM Report Pearls 11/29/2017: Alcoholic Hepatitis

Thank you to Anjali for presenting a great case of alcoholic hepatitis complicated by possible cholecystitis (MRCP pending……). We reviewed the use of steroids in alcoholic hepatitis.

Please see this great Blog Post on Alcoholic Hepatitis, by our former ZSFG Chief Dr. Carly Zapata (info included in Evernote link below).

 

Alcoholic Hepatitis

Etiology:
  • Most patients who develop alcoholic hepatitis have a history of heavy alcohol use for at least a decade, but it can occur with intermittent heavy drinking and over much shorter periods in some patients
Evaluation:
  • Alc hep labs will be most notable for an elevated INR and T bili with only a moderate elevation in transaminases. Many will also have a leukocytosis
Treatment:
  • Severity is calculated using the Maddreys’ discriminant function. Easiest to plug the T Bili and PT into MedCalc, but here is the formula for your reference:
    • DF = 4.6 x (patient prothrombin time – control) + T bili
  • Treatment with steroids has been shown to improve mortality for those with severe alc hep, though steroids may be contraindicated if there is concern for GI bleeding, infection, or renal failure.
    • Recommended steroid treatment is with prednisolone, since the liver usually metabolizes prednisone to the active prednisolone!
  • For severe alc hep with contraindications to steroids, pentoxifylline is an alternative, though data is weaker than for steroids and it has not been definitely shown to improve mortality (STOPAH trial from NEJM below)
    • Supportive care with nutrition, PPI and abstinence from alcohol are also important!
  • If there is no improvement in the DF after 1 week of therapy, ongoing treatment is not recommended and thought to have little benefit.
  • For patients with severe alc hep (DF ≥32) who do not receive treatment, mortality at 1 month is over 25%, primarily due to sepsis, GI bleeding and liver failure.
Lille Model for Alcoholic Hepatitis:
The Lille Model risk stratified patients already receiving steroids for alcoholic hepatitis for 7 days to predict which patients will not improve and should be considered for other management strategies.
  • 6 Factors in model: age, renal insufficiency (Cr >1.3 or CrCl <40), albumin, PT, initial bilirubin, and bilirubin at day 7)
  • Score greater than 0.45 correlates to a marked decrease in survival compared to others 25% vs 85%.
  • This model identified about 75% of the deaths in the cohort
  • Validates in additional study, which used a cut off of >=0.56
  • Patients who are failing to response to therapy may need to be referred to liver transplant
  • Of note, liver transplant for alcoholic hepatitis is controversial at this time and should be discussed with local experts.

 

Evernote:

  • Alcoholic Hepatitis: https://www.evernote.com/shard/s509/sh/46392762-07dc-40bc-999e-4b327eaf4284/139fa6e4da0ab588d8b20115aaf413a5

Sources:

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