Continuing Education Activity

Alcoholic hepatitis is a severe syndrome related to alcoholic liver disease. It is characterized by rapid onset of jaundice, malaise, tender hepatomegaly, and subtle features of systemic inflammatory response. This activity reviews the evaluation and management of alcoholic hepatitis and highlights the role of the interprofessional team in the recognition and management of this condition.

Objectives:

• Identify the etiology of alcoholic hepatitis.

• Outline strategies for decreasing alcohol dependency in patients with alcoholic hepatitis.

• Review the treatment options available for alcoholic hepatitis.

• Describe interprofessional team strategies for improving care coordination and communication to improve outcomes in patients with alcoholic hepatitis.

Introduction

Excessive alcohol consumption could result in fatty liver disease or steatosis, alcoholic hepatitis (AH), and eventually cirrhosis. Alcoholic hepatitis is a severe syndrome of alcoholic liver disease (ALD), characterized by rapid onset of jaundice, malaise, tender hepatomegaly, and subtle features of systemic inflammatory response. The recent worsening profile and trends of patients with AH-related hospitalizations in the United States suggest its importance in the current realm of clinical practice with its subsequent management.[1][2][3][4]

Alcoholic hepatitis usually progresses to cirrhosis if drinking is continued. For those who discontinue alcohol, hepatitis returns to normal within a few months but the cirrhosis that has already occurred does not reverse.

Etiology

The National Institute on Alcohol Abuse and Alcoholism (NIAAA), Alcoholic Hepatitis Consortia defines alcoholic hepatitis to include the following:

• The onset of jaundice within 60 days of heavy alcohol consumption (more than 50 g/day) for a minimum of 6 months
• Serum bilirubin more than 3 mg/dL
• Elevated aspartate aminotransferase (AST) to 50 U/L to 400 U/L 
• AST:ALT (alanine aminotransferase) ratio of more than 1.5
• No other cause of acute hepatitis

While using the terminology alcoholic hepatitis, it is important to understand the difference between alcoholic steatohepatitis (ASH) and alcoholic hepatitis (AH). About 20% to 40% of those who drink alcohol in heavy amounts and have fatty liver eventually develop liver inflammation, which is known as ASH. ASH is a diagnosis based on liver histology, while AH is a clinical diagnosis. The typical features of ASH on liver biopsy are steatosis, hepatocyte ballooning, infiltration of neutrophils, Mallory-Denk hyaline inclusions, and zone 3 perivenular injury with pericellular fibrosis or chicken-wire pattern of fibrosis. AH, on the other hand, is characterized by a history of chronic heavy alcohol consumption until at least 3 to 4 weeks before the onset of jaundice, fever, tachycardia, tachypnea, hepatomegaly, leukocytosis with neutrophilia, and an AST:ALT elevation greater than 1.5:1 with the absolute value of AST/ALT typically never exceeding 500 U/L. AH can occur in patients with any stage of alcoholic liver disease.

Although the amount of alcohol ingested is the most important risk factor for the development of chronic liver disease, the progression to alcohol-induced chronic liver disease is neither dose-dependent nor is the correlation with the quantity of alcohol consumed and liver injury linear. Even shorter durations of alcohol abuse could lead to AH. A typical patient would be between 40 to 60 years of age with a history of more than 100 g/day of alcohol consumption for a decade, in whom you have ruled out other causes of acute hepatitis. Risk factors include a high BMI (body mass index), female sex, and having a genetic variant of patatin-like phospholipase domain-containing protein 3 (PNPLA3). Clinical jaundice is a poor prognostic factor. Acute binge drinking is likely the trigger for AH in patients with a history of chronic, heavy alcohol abuse.[5][6][7][8]

Epidemiology

Approximately two-thirds of adults in the United States drink alcohol, while 7.2% suffer from alcohol use disorder (AUD). Excessive alcohol intake is the third leading preventable cause of death in the United States. A 10-year survey, from 2001 through 2011 from 211 hospitals revealed a 0.08% to 0.09% admissions related to alcoholic hepatitis.

Pathophysiology

Alcohol undergoes an oxidative metabolic pathway in the hepatocytes, leading to a reduced ratio of the nicotinamide adenine dinucleotide (NAD) to NADH. This promotes lipogenesis by inhibiting the oxidation of triglycerides and fatty acids.

Another known mechanism of alcohol-induced liver injury is the translocation of endotoxins in the form of lipopolysaccharides (LPS), from the intestines into the hepatocytes. In the hepatic Kupffer cells, the LPS binds to CD 14 and toll-like receptor 4 to release a barrage of reactive oxygen species (ROS). The ROS activates the release of cytokines such as tumor necrosis factor-alpha (TNF alpha), interleukin-8, monocyte chemotactic protein 1 (MCP-1), and platelet-derived growth factor (PDGF), all of which leads to the accumulation of neutrophils, macrophages, and systemic clinical features of alcohol injury.

Recent studies indicate that patients with specific intestinal dysbiosis have been increasingly susceptible to alcoholic liver disease and AH.

Histopathology

A liver biopsy is generally not required to make the diagnosis of alcoholic hepatitis, except in uncertain cases to delineate the etiology of the hepatic injury. The classical histological features include steatosis, hepatocellular ballooning representing steatohepatitis, cholestasis, chicken-wire fibrosis, cirrhosis in severely ill patients, neutrophilic and lymphocytic infiltration, and Mallory-Denk bodies.

History and Physical

The clinical presentation ranges from mild to severe. A mild clinical presentation would be a patient presenting with fever, right upper quadrant pain or discomfort, and elevations in aminotransferases that normalizes with sobriety. While a severe presentation would include jaundice, ascites, hepatic encephalopathy, and coagulopathy.

The physical exam may reveal tachycardia, tachypnea, fever, enlarged liver, and signs of portal hypertension. Spider angiomas, proximal muscle wasting, and gynecomastia are seen in severe cases of liver cirrhosis.

Evaluation

The diagnosis of alcoholic hepatitis is a clinical one with supporting laboratory findings of AH. All patients should have had an abdominal imaging study to exclude biliary obstruction and liver diseases such as hepatocellular carcinoma and liver abscess.

Liver tests may show elevation of AST, whereas ALT is usually in the normal range. This is the opposite of what is seen in other liver disorders. Carbohydrate-deficient transferrin is the most reliable marker of chronic alcoholism.

Ultrasound is the first imaging test of choice to assess patients with alcoholic hepatitis; it can be used to exclude gallstones and other biliary tract disorders. A liver biopsy is not always required but is useful for excluding other disorders. A liver biopsy should be done with care as these patients may have coagulopathy and thrombocytopenia.

Several trials and models exist to determine the severity of alcoholic hepatitis, to ascertain which patients would likely benefit from a pharmacological approach. In 1977, the Maddrey discriminant factor (MDF), included serum total bilirubin and prothrombin time to segregate patients with a 28-day mortality risk of greater than 50%. These patients had an MDF greater than 32 and were deemed to benefit from steroid therapy. Subsequent scoring systems included the model for end-stage liver disease (MELD) score, the ABIC score (including the age, bilirubin, international normalized ratio, and the creatinine score), the Glasgow AH score (including the age, bilirubin, international normalized ratio, blood urea nitrogen, and the peripheral white blood count) and the Lille score. The Lille score obtains data from the beginning and end of the first week of steroid therapy to assess response and subsequent need for further steroid therapy. A histological scoring system for the prognosis of patients with alcoholic hepatitis has also been proposed. Various combinations of scoring systems have been studied to predict outcomes accurately, and the combination of the MELD and the Lille score is one. [9][10][11][12]

Recent studies indicate that CRP is a good marker of alcoholic hepatitis.

Treatment / Management

Abstinence along with adequate nutritional support remains the cornerstone of the management of patients with alcoholic hepatitis. An addiction specialist could help individualize and enhance the support required for abstinence. About 10% to 20% of patients with AH are likely to progress to cirrhosis annually, and 10% of the individuals with AH have regression of liver injury with abstinence.

Patients with AH are subdivided into mild-moderate AH or severe AH. Patients with an MDF greater than 32, MELD score greater than 20, ABIC score category C, or a Glasgow AH score of 9 predicts higher mortality with a diagnosis of severe AH. Patients with severe AH with or without hepatic encephalopathy are considered candidates for a short course of prednisolone (40 mg/day for 28 days). Prednisolone is preferred to prednisone as it does not require metabolism in the liver for its therapeutic efficacy. For patients unable to take it orally, methylprednisolone, 32 mg intravenously daily, is an option. However, failure to respond to steroids within a week evident by a Lille score of greater than 0.45 indicates a lack of response to steroids which should be discontinued, thereafter. For patients with a Lille score of less than 0.45 (Lille responders), prednisolone should be continued for another three weeks. Glucocorticoids alter the expression of anti-inflammatory genes, thus promoting its anti-inflammatory role. Contraindications to steroid use include any active gastrointestinal (GI) bleeding, severe pancreatitis, uncontrolled diabetes, active infection, or renal failure. Such patients may be managed with pentoxifylline (400 mg orally, three times a day for 28 days). Hepatorenal syndrome is one of the major causes of death in patients with AH. Patients with acute kidney injury or hepatorenal syndrome respond poorly to corticosteroid therapy. Patients with bacterial infection may be treated with corticosteroids after the infection has been appropriately controlled with antibiotics. Response to prednisolone is graded as complete if Lille score is less than 0.16, partial if Lille score is between 0.16 and 0.56, or null if Lille score is greater than 0.56. A Lille score of more than 0.45 after 1 week of corticosteroid therapy is associated with 75% mortality at 6 months.[13]

Many recent trials, including the STOPAH trial and meta-analysis of the use of steroids and Pentoxifylline, reveal only short-term (28-day) mortality improvements with not much difference of 6-month, or 1-year mortality. In the STOPAH trial, however, patients with less severe AH were included, and most patients were recruited with a clinical diagnosis of AH. Thus it is possible that patients with decompensated alcoholic cirrhosis may have received a diagnosis of AH, which significantly alters the result of the trial. Anti-TNF (tumor necrosis factor) agents like Infliximab and Etanercept have been used with no proven survival benefits. Anti-TNF agents may even increase the incidence of infections and death.

Patients with AH are prone to infections, especially when on steroids. This is particularly important as it might lead to a poor prognosis, acute renal injury, and multi-organ dysfunction. Patients with AH are at risk of alcohol withdrawal. Lorazepam and oxazepam are the preferred benzodiazepines for prophylaxis and treatment of alcohol withdrawal. Daily caloric intake should be documented in patients with AH, and nutritional supplementation (preferably via mouth or NG tube) should be considered if oral intake is less than 1200 kcal in a day.

Both pentoxifylline and prednisolone are recommended for severe alcoholic hepatitis but long-term benefits remain questionable.

Liver transplantation could be considered for patients not responsive to steroids and with a MELD of greater than 26. However, varied barriers including fear of recidivism, organ shortage, and social and ethical considerations exist. A survey of liver transplant programs conducted in 2015 revealed only 27% of the programs offering a transplant to AH patients. Of the 3,290 liver transplants performed 1.37% were on AH patients. The six months, one-year, and 5-year survival was 93%, 93%, and 87% respectively, the outcomes of which are comparable to patients with similar MELD scores. The recidivism rates are similar (17%) to patients transplanted for alcohol-related cirrhosis.

If the patient has acute renal failure, nephrology should be consulted to rule out hepatorenal syndrome.

If the patient has a change in mental status, develops seizures or focal deficits, a neurologist should be consulted. In addition, if the patient has leucocytosis and fever and there is a concern for an infection, an infectious disease consult should be obtained.

Differential Diagnosis

The differential diagnoses of alcoholic hepatitis include nonalcoholic steatohepatitis, acute or chronic viral hepatitis, drug-induced liver injury, fulminant Wilson disease, autoimmune liver disease, alpha-1 antitrypsin deficiency, pyogenic hepatic abscess, ascending cholangitis, or decompensation associated with hepatocellular carcinoma.

Prognosis

Patients with severe alcoholic hepatitis with an MDF greater than 32 have 30-day mortality of 30% to 50%. Forty percent of the patients with severe alcoholic hepatitis die within 6 months after the onset of the clinical syndrome. Jaundice and hepatic encephalopathy at the time of presentation indicate a poorer outcome.

Mild alcoholic hepatitis generally runs a benign course and is completely reversible with the cessation of alcohol consumption.

To determine prognosis the following factors need to be considered:

• Histologically proven alcohol hepatitis
• Serum bilirubin greater than 2.5 mg/dl
• Serum albumin less than 2.5 g/dl
• Prothrombin time more than 5 seconds

Complications

Following are some common complications of alcoholic hepatitis:

• Variceal hemorrhage
• Hepatic encephalopathy
• Coagulopathy
• Thrombocytopenia
• Ascites
• Spontaneous bacterial peritonitis
• Iron overload

Postoperative and Rehabilitation Care

A diet consisting of 100 g/day of protein should be recommended. This should be supplemented with multivitamins including folate and thiamine. Protein-energy malnutrition is very common in alcoholics and associated with high mortality when compared to patients with no malnutrition. Unless the patient has encephalopathy, protein should not be restricted.

Deterrence and Patient Education

Patients with alcoholic hepatitis need long-term follow-up. Many can benefit from attending AA or a similar abuse treatment program. Serology for viral hepatitis should be ordered and period surveillance for liver cancer is recommended.

Patients with alcoholic hepatitis should be immunized against hepatitis A, hepatitis B, influenza A virus, and pneumococcus.

Pearls and Other Issues

The combination of systemic illness, malnutrition, concurrent renal injury, infections, lack of response to glucocorticoids or pentoxifylline result in poorer outcomes in severe alcoholic hepatitis. Further understanding of the pathophysiology of alcohol-induced liver injury, early recognition, including complications and potentially better pharmacological approach could in the future improve clinical outcomes in patients with severe AH. A better understanding of alcohol-related liver injury, inflammation, liver fibrosis, and liver regeneration and associated gut-barrier permeability and dysfunction, along with newer pharmacological breakthroughs to treat AH would likely improve our present management strategies.

Enhancing Healthcare Team Outcomes

Alcoholic hepatitis has repercussions beyond the liver and is best managed by an interprofessional team that includes physicians, physician assistants, and nurse practitioners. The primary care provider and nurse practitioner should educate patients on the harms of alcohol and if alcoholic hepatitis is suspected, quickly refer them to a gastroenterologist for further workup. The disorder can affect the functioning of multiple organs, and early diagnosis is important.

At every opportunity, the key to treatment is patient education about the health risks of alcohol.  Patients with severe alcoholic hepatitis with an MDF greater than 32 have 30-day mortality of 30% to 50%. Forty percent of the patients with severe alcoholic hepatitis die within 6 months after the onset of the clinical syndrome. Jaundice and hepatic encephalopathy at the time of presentation indicate a poorer outcome.

Nurse practitioners, pharmacists, and primary care providers should urge patients to enter AA and take their family members; there is evidence that this program can help some patients with alcoholism become sober. Other patients may need mental health counseling and cognitive behavior therapy.

The combination of systemic illness, malnutrition, concurrent renal injury, infections, lack of response to glucocorticoids or pentoxifylline result in poorer outcomes in severe AH. Further understanding of the pathophysiology of alcohol-induced liver injury, early recognition, including complications and potentially better pharmacological approach could in the future improve clinical outcomes in patients with severe AH. A better understanding of alcohol-related liver injury, inflammation, liver fibrosis, and liver regeneration and associated gut-barrier permeability and dysfunction, along with newer pharmacological breakthroughs to treat AH would likely improve our present management strategies. 

Those with end-stage liver should be referred to a transplant nurse to determine eligibility. The transplant nurse should assist in coordination for transplant and report findings to the clinical transplant surgeon and hepatologist managing the case. Due to the complexity of care, an interprofessional team of specialty-trained nurses and clinicians should coordinate the long-term care of these patients.[14] [Level V]