Alcoholic Hepatitis

Alcohol-associated (alcoholic) hepatitis is an acute inflammatory liver injury resulting from heavy alcohol consumption, typically in the context of a recent significant increase in intake superimposed on a background of chronic alcohol use, representing a distinct acute clinical syndrome from the broader spectrum of alcohol-related liver disease that also includes steatosis and cirrhosis (see that entry).

Severity ranges from mild, self-limiting disease to severe disease with high short-term mortality.

Jaundice (often the presenting feature), fever, tender hepatomegaly, and features of decompensation in more severe cases (ascites, encephalopathy, coagulopathy), typically in a patient with a clear history of heavy, sustained alcohol use.

Signs of chronic liver disease (spider angiomata, palmar erythema) may or may not be present depending on whether underlying cirrhosis has already developed.

• LFTs show a characteristic pattern: AST typically elevated but rarely above 300 to 400 IU/L, with an AST:ALT ratio greater than 2 (reflecting relative ALT deficiency from alcohol-related pyridoxal-5-phosphate depletion), alongside elevated bilirubin and, in more severe disease, prolonged INR
• FBC often shows a neutrophilic leukocytosis (can mimic sepsis and should prompt active screening for concurrent infection, which is common and important not to miss) and macrocytic anemia
• Severity is stratified using the Maddrey discriminant function: DF = 4.6 × (patient's PT − control PT in seconds) + serum bilirubin (mg/dL); a DF of 32 or above indicates severe disease with significant short-term mortality risk and is the threshold used to consider corticosteroid therapy
• The Glasgow Alcoholic Hepatitis Score and MELD score are alternative/complementary severity and prognostic tools used in some centers
• Liver biopsy (transjugular, given the frequent coagulopathy) is reserved for diagnostic uncertainty rather than routine use
• Active screening for infection (given the elevated risk and the fact that untreated infection is a contraindication to corticosteroid therapy) and for other alcohol-related complications (Wernicke's encephalopathy risk, pancreatitis)

• Alcohol abstinence is the single most important intervention, with addiction support and management of alcohol withdrawal (see general alcohol withdrawal principles) initiated concurrently
• Nutritional support is essential given near-universal malnutrition in this population, with adequate protein intake (1.2 to 1.5 g/kg/day, not restricted despite hepatic impairment, given evidence that protein restriction worsens outcomes) and thiamine supplementation (given before or with any glucose administration, to prevent precipitating Wernicke's encephalopathy)
• Corticosteroids: prednisolone 40 mg PO od for 28 days, then tapered, is considered for severe disease (DF ≥32) in the absence of active infection, GI bleeding, or renal failure, following screening and treatment of any infection first; benefit is modest and short-term (improved 28-day but not clearly improved 90-day or long-term survival in more recent trial evidence), and response is reassessed at day 7 using the Lille score, with corticosteroids stopped if the Lille score indicates non-response, since continued treatment offers no benefit and adds infection risk in non-responders
• Pentoxifylline was historically used as an alternative or adjunct but current evidence does not support a clear survival benefit, and it has been largely superseded by the corticosteroid-with-Lille-score-reassessment approach above
• Screen for and treat infection aggressively given the significantly elevated risk and its major impact on mortality
• Liver transplantation is increasingly considered for select patients with severe, corticosteroid-non-responsive alcoholic hepatitis at specialist centers with structured sobriety and psychosocial assessment protocols, a significant shift from historical rigid sobriety-duration requirements
• Manage complications of decompensation (ascites, encephalopathy, coagulopathy) per the principles in the Cirrhosis entry

Referral: hepatology for all cases, urgently for severe disease (DF ≥32) given the corticosteroid decision window and mortality risk; addiction services for alcohol use disorder management.