Management of Alcoholic Hepatitis

Assessment and Diagnosis

The American Association for the Study of Liver Diseases recommends evaluating severity using validated prognic models: Maddrey Discriminant Function (MDF), MELD score, Glasgow Alcoholic Hepatitis Score (GAHS), or ABIC score 1, 3
A MDF ≥32 or MELD >20 indicates severe alcoholic hepatitis with high 28-day mortality (30-50%) 1, 3
Obtain blood, urine, and ascites (if present) cultures to rule out infection regardless of fever presence 1
Consider liver imaging while avoiding iodinated contrast due to increased risk of acute kidney injury 1
Liver biopsy via transjugular route may be considered for definitive diagnosis in unclear cases, especially when considering corticosteroid treatment 3, 4

Hospitalize patients with severe alcoholic hepatitis or those with inadequate social/medical support to ensure abstinence, restore nutrition, and exclude infections 1
Implement alcohol abstinence counseling and support immediately 1, 2
Provide nutritional support with 1-1.5g protein and 30-40 kcal/kg body weight daily 1
Consider enteral feeding via nasogastric tube if patient cannot eat due to anorexia or altered mental status 1
Avoid nephrotoxic drugs including diuretics, as acute kidney injury is an early manifestation of multi-organ failure 1

For severe alcoholic hepatitis (MDF ≥32 or MELD >20) without contraindications, administer methylprednisolone 32 mg daily 1, 5
Consider combination of N-acetylcysteine with corticosteroids, which has shown short-term survival benefit at 1 and 3 months in one study 5
Assess response to corticosteroid therapy after 7 days using the Lille model; scores ≥0.45 indicate poor response with high 6-month mortality 6

Refer patients with severe alcoholic hepatitis (particularly MELD >26) with good insight into their alcohol use disorder and strong social support for liver transplantation evaluation 1
The 90-day mortality rate is very high in these patients without transplantation 1

Combine Lille and MELD scores for optimal evaluation of short and medium-term mortality risk 5
Monitor for infections during treatment, especially in patients on corticosteroids 1, 5
Provide B vitamins and folic acid supplementation 2
Focus on long-term abstinence as it significantly improves 5-year survival (80% with abstinence vs. 50% with relapse) 5

For patients with mild to moderate disease (MELD <20, MDF <32), focus on abstinence counseling and nutritional support 1, 2
Prescribe high protein diet supplemented with B vitamins and folic acid 1
Even in these "less severe" cases, recognize that mortality remains significant (10% at 6 months, 20% at 1 year) 4

Do not delay assessment of disease severity - early stratification is crucial for timely intervention 1, 3
Do not overlook infections which can precipitate multi-organ failure; perform thorough infection screening 1
Avoid iodinated contrast agents which increase risk of acute kidney injury 1
Do not rely on parenteral nutrition alone as it is inadequate for recovery 1
Remember that most patients with alcoholic hepatitis already have underlying cirrhosis at diagnosis 1