Management of Haematemesis in Alcoholic Hepatitis

Immediate Assessment and Stabilization

The American Association for the Study of Liver Diseases recommends that all patients with alcoholic hepatitis presenting with haematemesis must be hospitalized immediately to manage the acute bleeding, encourage alcohol abstinence, and exclude serious bacterial infections that commonly precipitate decompensation 1
Obtain cultures of blood, urine, and ascites (if present) immediately upon admission, regardless of fever presence, as infections are both precipitating events and factors leading to poor outcomes 1, 2
Fever and elevated white blood cell counts are unreliable indicators of infection in alcoholic hepatitis; maintain high clinical suspicion for bacterial and fungal infections 2, 3
The presence of systemic inflammatory response syndrome (SIRS) on admission significantly increases risk of multi-organ failure (MOF), which carries extremely high mortality 1, 4

Avoid or use diuretics sparingly, as acute kidney injury (AKI) is an early manifestation of MOF and can develop from infection, intravascular volume depletion, or nephrotoxic drugs 1, 5
Do not administer iodinated contrast dye for imaging, as this significantly increases AKI risk in patients with cirrhosis, similar to risks seen in diabetes and heart failure 5, 3
Maintain careful fluid balance to prevent both volume depletion (which precipitates AKI) and volume overload 5

Perform urgent upper endoscopy to identify the bleeding source, recognizing that the majority of patients with alcoholic hepatitis have underlying cirrhosis at diagnosis 1, 6
Common bleeding sources include esophageal or gastric varices (from portal hypertension) and erosive gastritis from alcohol-induced mucosal damage, according to the American Gastroenterological Association 7

Assess severity using validated scoring systems: Maddrey Discriminant Function (MDF), MELD score, ABIC score, or Glasgow Alcoholic Hepatitis Score, as recommended by the European Association for the Study of the Liver 1, 6
MDF > 32 predicts high 28-day mortality; MELD > 20 predicts high 90-day mortality 1, 4
Without treatment and abstinence, 90-day mortality is 40-50% 1, 6

Provide 35-40 kcal/kg/day with protein intake of 1.2-1.5 g/kg/day (increase to 1.5 g/kg/day in severely ill patients), according to the American Association for the Study of Liver Diseases 7
Nutritional intake is a major determinant of mortality; patients consuming < 21.5 kcal/kg/day have significantly lower survival 3
If the patient cannot eat due to anorexia or altered mental status, consider enteral feeding via nasogastric tube—parenteral nutrition alone is inadequate 1
Normal-to-high protein diets are safe and do not increase encephalopathy risk in alcoholic hepatitis, as stated by the European Society for Clinical Nutrition and Metabolism 5

For patients without contraindications (active infection, hepatitis B, tuberculosis, gastrointestinal bleeding), consider methylprednisolone 32 mg daily, as recommended by the American Association for the Study of Liver Diseases 1
However, glucocorticoids only modestly improve 28-day mortality and provide no benefit at 90 days or 1 year, largely due to increased infection risk 1, 2, 3
The combination of prednisolone plus N-acetylcysteine (NAC) intravenously over the first 5 days showed the most significant improvement in 1-month mortality (8% vs 24% with prednisolone alone) and reduced infections (19% vs 42%) 2, 3

Use the Lille score at day 7 to predict treatment response if glucocorticoids are initiated, as recommended by the European Association for the Study of the Liver 5, 8
Discontinue glucocorticoids in patients who fail to improve based on Lille criteria 5, 8
Patients with MELD > 26 should be considered for liver transplantation, which may be life-saving, according to the United Network for Organ Sharing 5, 8

Abstinence from alcohol is the absolute cornerstone of treatment and essential for long-term survival, as stated by the American Association for the Study of Liver Diseases 1, 2, 3
Patients who return to heavy drinking have far worse prognosis than those who remain abstinent 2, 3
Implement brief alcohol intervention during hospitalization, which reduces future alcohol consumption by approximately 41 g/week, according to the National Institute on Alcohol Abuse and Alcoholism 7
Arrange extended alcohol counseling after discharge to maintain abstinence 7