Written by Laura Murphy
Patients with alcohol-associated hepatitis have a high rate of complications and short-term mortality of 20-50%. Prompt recognition and treatment, including initiation of treatment for alcohol use disorder, is important to improve patient outcomes.
Why does this matter?
Alcohol is responsible for 50% of deaths due to liver disease, and 35% of patients with alcohol use disorder will develop some form of alcoholic liver disease (ALD). As incidence of alcohol-associated liver disease is increasing, it is imperative that emergency physicians recognize and initiate appropriate treatment for patients presenting with alcohol-associated hepatitis, which carries a particularly high short-term mortality rate.
Whiskey, you’re the devil…
Alcoholic hepatitis is a severe clinical state characterized by abrupt onset of jaundice, malaise, decompensated liver disease, and coagulopathy. Severe cases have an estimated 3-month mortality of 20-50%. Hepatocellular failure and portal hypertension is caused by a variety of cellular and molecular pathways causing direct hepatotoxicity, changes in the gut-liver axis, and associated local and systemic inflammatory response.
Diagnosis: Signs and symptoms include jaundice, malaise, ascites or edema, fever, tender hepatomegaly, confusion and/or asterixis; lab findings include hyperbilirubinemia, transaminitis with AST>ALT, hypoalbuminemia, thrombocytopenia and increased INR. NIAAA Consortium criteria include prolonged alcohol intake (>60 g/day for men, >40 g/day for women) until <8 weeks prior to presentation, acute onset of jaundice with bilirubin >3 mg/dL, AST> 50 IU/L, AST:ALT>1.5 (with both values <400 IU/L). It is important to rule out other causes of liver disease including obstruction, drug-induced injury, viral hepatitis, or ischemia and to treat if present. Biopsy can be pursued in ambiguous cases.
Complications: Liver-related complications include ascites, edema, hepatic encephalopathy (which portends a particularly poor prognosis) as well as GI bleeding, and hepatorenal syndrome. Patients generally require aggressive nutritional support and vitamin supplementation. Workup and treat concomitant infections (up to 12.5% of patients present with a concomitant infection, and 23% develop infection during treatment). Incidence of fungal infections is high (up to 16%) in this population.
Treatment: Glucocorticoids (prednisone 40 mg/day) decrease short-term mortality for patients with MELD>20. Concomitant use of N-acetylcysteine has also shown promise for improving short-term survival. For patients who do not respond to steroids, early liver transplantation should be considered. However, there are often barriers to transplant, including psychosocial factors, stigma, and selection bias.
The main factor influencing long-term prognosis after an episode of alcohol-associated hepatitis is prolonged abstinence, so initiation of treatment for alcohol use disorder is imperative! This includes treatment for withdrawal, identification and treatment of concomitant psychiatric conditions, consultation with addiction specialists, behavioral therapy, and consideration of anti-craving drugs at discharge (baclofen and acamprosate best for patients with ALD).
Alcohol-Associated Hepatitis. NEJM. 2022 Dec 29; 387 (26): 2436-2448.