Alcoholic hepatitis

Definition. An acute clinical syndrome of rapid onset or worsening of jaundice in a patient with sustained heavy alcohol use, with underlying histological steatohepatitis. Severe disease may progress to acute-on-chronic liver failure with a 1-month mortality of 20–50%.

Diagnostic criteria (NIAAA). Onset of jaundice within 8 weeks; ongoing heavy alcohol use (>40 g/day in women, >60 g/day in men) for ≥6 months with fewer than 60 days abstinence before onset; AST >50 IU/L with AST:ALT ratio >1.5 and both below 400 IU/L; bilirubin >3 mg/dL; and exclusion of other liver disease. Biopsy is not needed unless there are confounding factors.

Clinical features. Tender hepatomegaly, fever, anorexia, ascites, encephalopathy and neutrophil leucocytosis. In older patients alcohol misuse is frequently unrecognised, and presentation may be with confusion, falls, malnutrition or unexplained jaundice.

Severity scores. Maddrey Discriminant Function ≥32 defines severe disease; MELD >20 is the most accurate score; also the Glasgow Alcoholic Hepatitis Score and the ABIC score. The Lille score at day 7 — a value >0.45 indicates steroid non-response and steroids should be stopped.

General management. Abstinence is the single most important determinant of survival. Manage alcohol withdrawal (benzodiazepines cautiously in the elderly — prefer lorazepam, which has no active metabolites), give thiamine before any glucose, provide aggressive nutrition (35 kcal/kg and 1.2–1.5 g/kg protein) preferably enterally, actively look for and treat infection, avoid nephrotoxins, and manage acute kidney injury, electrolytes and encephalopathy.

Specific therapy. Prednisolone 40 mg daily for 28 days in severe disease (DF ≥32 or MELD >20), after excluding active infection, gastrointestinal bleeding and renal failure; reassess with the Lille score at day 7. Pentoxifylline is no longer recommended. Long-term care involves treating alcohol use disorder (baclofen is preferred in cirrhosis; acamprosate and naltrexone are limited by hepatotoxicity), vaccination, and consideration for transplantation.

ACG Clinical Guideline 2024 (Am J Gastroenterol 2024;119:30) — adopts the term "alcohol-associated liver disease"; recommends corticosteroids with adjuvant intravenous N-acetylcysteine for severe alcohol-associated hepatitis; recommends against pentoxifylline and against routine prophylactic antibiotics; and gives a stronger recommendation for early liver transplantation in steroid non-responders at low risk of relapse, explicitly stating that candidacy must not be based on an arbitrary 6-month sobriety rule but on structured psychosocial assessment (SALT score, Stanford Integrated Psychosocial Assessment Tool).