Alcoholic hepatitis

Last updated: May 13, 2022

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Alcoholic hepatitis is a clinical syndrome with a broad range of manifestations, from vague malaise to fulminant liver failure. Alcoholic hepatitis should be suspected in patients with prolonged heavy alcohol use and recent-onset jaundice, fever, leukocytosis, and tender hepatomegaly. Characteristic findings from liver chemistries in alcoholic hepatitis include transaminitis and hyperbilirubinemia. A diagnosis of acute alcoholic hepatitis requires consideration of confounding factors, including differential diagnoses of alcoholic hepatitis, uncertain alcohol use, and atypical laboratory results. Laboratory-based prognostic scores (e.g., Maddrey discriminant function and MELD scores) can be used to assess severity and short-term prognosis and guide management. Complete abstinence from alcohol is advised for all patients and is considered the most effective intervention. Supportive management includes nutritional support, monitoring for alcohol withdrawal syndrome, and treatment for alcohol use disorder. Patients with severe alcoholic hepatitis may benefit from pharmacotherapy with glucocorticoids or, in selected cases, early liver transplantation. Patients with no response to glucocorticoids who are not candidates for early liver transplantation should be referred for palliative care.

  • Incidence: ∼ 0.8% of all hospitalizations in the US per year [1][2]
  • Survival [3]
    • 4-year survival: ∼ 58%
    • 1-year survival in patients with concomitant cirrhosis: ∼ 35%
    • 6-month survival for severe alcoholic hepatitis that does not respond to medical therapy: ∼ 30%

Epidemiological data refers to the US, unless otherwise specified.

Acute alcoholic hepatitis may be reversible in mild cases. [1][2]

Symptoms of alcoholic hepatitis are nonspecific. The presence of acute-onset jaundice can help differentiate acute alcoholic hepatitis from decompensated cirrhosis. [5]

These recommendations are consistent with the 2019 American Association for the Study of Liver Diseases (AASLD) and 2018 American College of Gastroenterology (ACG) clinical guidelines. [1][2]

Approach [1][2]

Suspect alcoholic hepatitis in patients with suggestive clinical features and a history of chronic heavy alcohol use.

The presence of systemic inflammatory response syndrome (SIRS) criteria at admission is a predictor of multiorgan failure (especially AKI) and early death. [1][2]

Infections are common in patients with alcoholic hepatitis and are associated with a poorer prognosis. An infectious disease workup is recommended in all patients with alcoholic hepatitis. [1]

Consensus definitions for alcoholic hepatitis [2][3]

The AASLD recommends classifying patients according to the consensus definitions.

Initial studies [1][6]

Laboratory studies

AST > ALT in alcoholic hepatitis: Remember “make a toAST with alcohol!”

Imaging studies

Obtain imaging studies in all patients to rule out differential diagnoses (e.g., biliary obstruction, cholangitis ).

Additional diagnostic workup [1][6]

Obtain additional studies to exclude differential diagnoses and identify comorbidities; workup should be guided by clinical suspicion and may include the following:

Sepsis should always be ruled out in patients with alcoholic hepatitis and SIRS.

Liver biopsy [1][2]

Histopathological findings of alcoholic steatohepatitis may be indistinguishable from findings of nonalcoholic steatohepatitis; the ANI can help differentiate between the two.

Prognostic scoring systems are used to guide management and determine disease severity. Severe alcoholic hepatitis is defined as Maddrey discriminant function ≥ 32 or MELD score > 20.

Noninvasive prognostic scoring systems in alcoholic hepatitis [1][2]
Description Interpretation
Maddrey discriminant function (MDF) [9][10]
Model for End-stage Liver Disease (MELD) score [11]
Lille model for alcoholic hepatitis [12]

AST > 400 IU/L should raise concern for drug-induced liver injury or ischemic hepatitis. [3]

The differential diagnoses listed here are not exhaustive.

These recommendations are consistent with the 2019 AASLD and 2018 ACG clinical guidelines. [1][2]

Approach [1][2]

Disposition [1]

Consider ICU admission in any of the following situations:

Supportive care

Alcohol cessation [1][2][5]

Alcohol cessation is the only management strategy with proven long-term benefits in alcoholic hepatitis. [2][4]

Alcohol cessation may lead to alcohol withdrawal syndrome. [1]

Nutritional support [1][2][5][13]

Patients with alcoholic hepatitis may be very malnourished. Consider specialist consultation for specialized nutritional support.

Pharmacological therapy [1][2][14][15]

Evidence regarding the benefit of pharmacological treatment for alcoholic hepatitis is mixed.

Glucocorticoids [1]

The AASLD and ACG recommend glucocorticoid use in selected cases.

Patients who do not respond within the first week of glucocorticoid treatment are unlikely to derive benefit from continued treatment. [1]

Other medications [15]

Other medications may be considered for patients with severe alcoholic hepatitis.

  • N-Acetylcysteine [16]
    • May reduce complications and mortality when given in combination with glucocorticoids
    • Evidence that N-acetylcysteine improves outcomes is limited, but the risks of treatment are low.
  • Pentoxifylline
    • No longer recommended by the AASLD
    • May be preferable to no intervention in specific situations (e.g., in patients with contraindications to glucocorticoid therapy, patients with AKI) [15]

Early liver transplantation [2][17]

  • Definition: liver transplantation without 6 months of abstinence from alcohol
  • Consider in patients with the following:
    • No response to supportive or pharmacological management
    • Favorable psychosocial profiles

Liver transplantation may be considered in selected patients with acute alcoholic hepatitis, even if they have not abstained from alcohol for the required 6 months.

  1. Crabb DW, Im GY, Szabo G, Mellinger JL, Lucey MR. Diagnosis and Treatment of Alcohol‐Associated Liver Diseases: 2019 Practice Guidance From the American Association for the Study of Liver Diseases. Hepatology. 2020; 71 (1): p.306-333. doi: 10.1002/hep.30866 . | Open in Read by QxMD
  2. Singal AK, Bataller R, Ahn J, Kamath PS, Shah VH. ACG Clinical Guideline: Alcoholic Liver Disease. Am J Gastroenterol. 2018; 113 (2): p.175-194. doi: 10.1038/ajg.2017.469 . | Open in Read by QxMD
  3. Thursz M, Morgan TR. Treatment of Severe Alcoholic Hepatitis. Gastroenterology. 2016; 150 (8): p.1823-1834. doi: 10.1053/j.gastro.2016.02.074 . | Open in Read by QxMD
  4. Crabb DW, Bataller R, Chalasani NP, et al. Standard Definitions and Common Data Elements for Clinical Trials in Patients With Alcoholic Hepatitis: Recommendation From the NIAAA Alcoholic Hepatitis Consortia. Gastroenterology. 2016; 150 (4): p.785-790. doi: 10.1053/j.gastro.2016.02.042 . | Open in Read by QxMD
  5. Muñoz M, Gómez-Ramírez S, Bhandari S. The safety of available treatment options for iron-deficiency anemia. Expert Opin Drug Saf. 2017; 17 (2): p.149-159. doi: 10.1080/14740338.2018.1400009 . | Open in Read by QxMD
  6. Hosseini N, Shor J, Szabo G. Alcoholic Hepatitis: A Review. Alcohol Alcohol. 2019; 54 (4): p.408-416. doi: 10.1093/alcalc/agz036 . | Open in Read by QxMD
  7. Grillet F, Calame P, Cervoni J-P, et al. Non-invasive diagnosis of severe alcoholic hepatitis: Usefulness of cross-sectional imaging. Diagn Interv Imaging. 2021; 102 (4): p.247-254. doi: 10.1016/j.diii.2020.09.009 . | Open in Read by QxMD
  8. Dunn W, Angulo P, Sanderson S, et al. Utility of a New Model to Diagnose an Alcohol Basis for Steatohepatitis. Gastroenterology. 2006; 131 (4): p.1057-1063. doi: 10.1053/j.gastro.2006.08.020 . | Open in Read by QxMD
  9. Thursz MR, Richardson P, Allison M, et al. Prednisolone or Pentoxifylline for Alcoholic Hepatitis. N Engl J Med. 2015; 372 (17): p.1619-1628. doi: 10.1056/nejmoa1412278 . | Open in Read by QxMD
  10. Pavlov CS, Varganova DL, Casazza G, Tsochatzis E, Nikolova D, Gluud C. Glucocorticosteroids for people with alcoholic hepatitis. Cochrane Database of Systematic Reviews. 2019; 2019 (4). doi: 10.1002/14651858.cd001511.pub4 . | Open in Read by QxMD
  11. Singh S, Murad MH, Chandar AK, et al. Comparative Effectiveness of Pharmacological Interventions for Severe Alcoholic Hepatitis: A Systematic Review and Network Meta-analysis. Gastroenterology. 2015; 149 (4): p.958-970.e12. doi: 10.1053/j.gastro.2015.06.006 . | Open in Read by QxMD
  12. Louvet A, Naveau S, Abdelnour M, et al. The Lille model: A new tool for therapeutic strategy in patients with severe alcoholic hepatitis treated with steroids. Hepatology. 2007; 45 (6): p.1348-1354. doi: 10.1002/hep.21607 . | Open in Read by QxMD
  13. Nguyen-Khac E, Thevenot T, Piquet M-A, et al. Glucocorticoids plusN-Acetylcysteine in Severe Alcoholic Hepatitis. N Engl J Med. 2011; 365 (19): p.1781-1789. doi: 10.1056/nejmoa1101214 . | Open in Read by QxMD
  14. Elfeki MA, Singal AK. Early Liver Transplantation: An Evolving Therapeutic Option for Alcohol-Associated Liver Disease. J Clin Exp Hepatol. 2022; 12 (1): p.3-5. doi: 10.1016/j.jceh.2021.10.144 . | Open in Read by QxMD
  15. Maddrey WC, Boitnott JK, Bedine MS, Weber FL, Mezey E, White RI. Corticosteroid therapy of alcoholic hepatitis. Gastroenterology. 1978; 75 (2): p.193-199. doi: 10.1016/0016-5085(78)90401-8 . | Open in Read by QxMD
  16. Carithers RL. Methylprednisolone Therapy in Patients with Severe Alcoholic Hepatitis. Ann Intern Med. 1989; 110 (9): p.685. doi: 10.7326/0003-4819-110-9-685 . | Open in Read by QxMD
  17. Kamath PS, Kim WR. The model for end-stage liver disease (MELD). Hepatology. 2007; 45 (3): p.797-805. doi: 10.1002/hep.21563 . | Open in Read by QxMD

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