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Alcoholic hepatitis
How is Alcoholic hepatitis diagnosed?
The ‘gold standard for diagnosis is liver biopsy. However this is often not feasible in the clinical setting due to the presence of ascites or coagulopathy. Transjugular liver biopsy is an option, but the expertise is often not available.
Can Alcoholic hepatitis be diagnosed clinically?
Suggested criterion:
NB- Characteristic features of alcoholic hepatitis (but not necessary for diagnosis) include pyrexia, hepatomegaly, a hepatic bruit, ascites, encephalopathy, an AST: ALT ratio greater than 1.5, and a peripheral leucocytosis.
How accurate is a clinical diagnosis of Alcoholic hepatitis?
An accuracy of about 80% has been quoted for the clinical diagnosis of alcoholic hepatitis when compared with histology. However if only those studies with a minimum level of bilirubin (>80 umol/l) as a criterion for diagnosis are looked at, the accuracy rises to nearly 100%.
Does alcoholic hepatitis with co-existing cirrhosis alters the prognosis or treatment?
Whilst nearly all patients who fulfil these criteria will have features of alcoholic hepatitis on biopsy, approximately 50-60% will also have established cirrhosis. There is no evidence that co-existing cirrhosis worsens the short term outcome of patients with alcoholic hepatitis, indicating that it is the acute inflammatory process which is primarily responsible for the poor prognosis of these patients. The presence of cirrhosis (confirmed or suspected) should therefore not prevent consideration of specific treatment for alcoholic hepatitis.
How do you assess the severity of Alcoholic Hepatitis?
American College of Gastroenterology defines severity as a modified Discriminant Function (mDF)> 32 and/or hepatic encephalopathy.
This is based on recent studies where a mDF> 32 and/or hepatic encephalopathy was associated with a 65% 28-day survival in placebo treated patients. While those with a score less than 32 had a survival of 93%.
Where would you use steroids?
American College of Gastroenterology recommends prednisolone should be used in patients with severe alcoholic hepatitis in whom the diagnosis is certain. Severity is defined as a DF> 32 and/or hepatic encephalopathy.
Histologic confirmation of alcoholic hepatitis optimizes the selection of those patients being considered for corticosteroid therapy. However, if the risk of performing liver biopsy is considered too great, the diagnosis can usually be made reliably by clinical and laboratory evaluation in the majority of patients.
The efficacy of steroids has not been adequately evaluated in patients with severe alcoholic hepatitis who also have concomitant pancreatitis, gastrointestinal bleeding, renal failure, and active infection.
Patients with mDF >32 and treated with steroids had a 28 day survival of 84.6% compared with 65.1% for placebo treated patients.
Is there any other clinical guide to help us better direct our treatment?
A GAHS (Glasgow alcoholic hepatitis score) has been recently developed. The authors of GAHS points out a few shortcomings of mDF;
What is GAHS?
1 | 2 | 3 | |
Age | <50 | >50 | |
WCC (109/l) | <15 | > 15 | |
Urea(mmol/l) | <5 | > 5 | |
PT ratio or INR | <1.5 | 1.5-2.0 | >2 |
Bilirubin (umol/l) | <125 | 125-250 | >250 |
Discuss GAHS Vs mDF?
Day 28 survival | Day 84 survival | |
Day 1 score | ||
GAHS <9 | 87 | 79 |
GAHS >9 | 46 | 40 |
DF > 32 | 71 | 62 |
Day 6-9 score | ||
GAHS <9 | 93 | 86 |
GAHS >9 | 47 | 37 |
Thus GAHS of 9 or more is much more discriminatory in identifying patients most at risk of death. A score of 9 or more can be used either on day 1 (admission day) or day6-9.
What is the steroid dose and duration?
Prednisolone 40 mg daily for four weeks followed by a taper.
Careful monitoring for evidence of infection, gastrointestinal bleeding, glucose intolerance, or renal failure is essential while the patient is on prednisolone therapy.
How do you assess response?
Any fall in serum bilirubin after one week of corticosteroid treatment is indicative of treatment response and good prognosis.
Are there any other treatments for Alcoholic Hepatitis?
The role for pentoxifylline whilst promising is as yet unproven. It acts by inhibiting TNF alpha.
What other supportive care can patients with Alcoholic hepatitis be provided?
Summary
Patients with severe disease (mDF > 32, or more specifically GAHS > 9) benefit from corticosteroids, and perhaps pentoxifylline.
References
Article printed from Gastroenterology Education and CPD for trainees and specialists: https://www.gastrotraining.com