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How is Alcoholic hepatitis diagnosed? History of recent excessive alcohol ingestion Serum bilirubin more than 80 umol/l ALT <300 IU (or AST<500 IU) Exclusion of autoimmune, chronic viral or malignant liver disease
Characteristic features of alcoholic hepatitis (but not necessary for diagnosis) Pyrexia, Hepatomegaly, A hepatic bruit, Ascites, Encephalopathy, AST: ALT ratio greater than 1. 5, 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.
Does alcoholic hepatitis with coexisting cirrhosis alters the prognosis or treatment?
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.
How do you assess the severity of Alcoholic Hepatitis?
Modified discriminant function (m. DF) Glasgow alcoholic hepatitis score (GAHS)
m. DF = 4. 6 (PTpatient–PTcontrol)+ serum bilirubin (µmol/l)/17. 1
American College of Gastroenterology defines severity as a modified Discriminant Function (m. DF)> 32 and/or hepatic encephalopathy.
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
m. DF> 32 and/or hepatic encephalopathy was associated with a 65% 28 -day survival <32 had a survival of 93%.
Patients with m. DF >32 and treated with steroids had a 28 day survival of 84. 6% compared with 65. 1% for placebo treated 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 – active infection.
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.
What other supportive care can patients with Alcoholic hepatitis be provided?
These patients are at risk of sepsis. Close vigilance for sepsis and a low threshold for the use of antibiotics is required. These patients have significant protein energy malnutrition. Nutritional support is vital for these patients.
What is GAHS?
Criticism of m. DF relies on the absolute value of the PT The presence of encephalopathy has often been included when making a treatment decision, in addition to just calculating the m. DF was highly sensitive in the prediction of death from alcoholic hepatitis but lacked specificity. This was dramatic as it incorrectly predicted the outcome at 28 days after admission in 51% of cases. They also suggests that even with a m. DF greater than or equal to 32, patients with a GAHS less than nine do not benefit from such treatment.
Are there any other treatments for Alcoholic Hepatitis?
Pentoxifylline, a phosphodiesterase inhibitor It acts by inhibiting TNF alpha. Dose 400 mg tds
One hundred one patients with severe alcoholic hepatitis (Maddrey discriminant factor > or = 32) entered a 4 -week doubleblind randomized trial of PTX (400 mg orally 3 times daily) vs. placebo Akriviadis E, Botla R, Briggs W, Han S, Reynolds T, Shakil O (2000). "Pentoxifylline improves short-term survival in severe acute alcoholic hepatitis: a double-blind, placebo-controlled trial". Gastroenterology 119 (6): 1637– 48
Twelve (24. 5%) of the 49 patients who received PTX and 24 (46. 1%) of the 52 patients who received placebo died during the index hospitalization (P = 0. 037; relative risk, 0. 59; 95% confidence interval, 0. 35 -0. 97).
Summary Non cirrhotic vs cirrhotic Typical blood test Assess severity Treatment with steroid and pentoxyphylline Nutrition and alcohol detox