Do I look fat??? or am I inflammed.....

The consequences of alcohol are not just fatty liver and cirrhosis....you need think about alcoholic hepatitis as the prognosis of severe cases can be quite poor....

Alcoholic hepatitis should be suspected in a patient with heavy alcohol use and certain clinical / laboratory findings which differentiate this entity from just fatty liver.

Clinically the patients classically present with fever (low grade), hepatomegaly, jaundice and anorexia. When examining the liver you may notice increased size, tenderness and listen for a bruit over the liver because you just might hear one! At least a third of these patients have ascites and signs of chronic liver disease. Because the symptoms may be also seen in conditions such as SBP it is important to keep a wide differential. Alcoholic hepatitis is often a diagnosis of exclusion.

Laboratory abnormalities expected in alcoholic hepatitis include the typical transaminitis abnormalities in chronic liver disease with additional elevation in ALP, GGT and bilirubin. A liver biopsy is generally not needed in the diagnosis but if performed would show:

• liver necrosis
• mallory bodies
• infiltrative neutophils
• perivenular distribution of inflammation

Treatment of alcoholic hepatitis includes abstinence from ETOH as well as supportive measures such as management of withdrawal symptoms and vitamin supplementation. The overall prognosis of the acute condition can be assessed using MADDREY’s DISCRIMNANT FUNCTION (Maddrey’s Score)

Discriminant Function = 4.6x (PT-control PT) + (serum bilirubin (umol/L) / 17)

If the value is greater than 32 there is a high short term mortality (eg. one month mortality >35)

There are multiple trials with mixed results about the efficacy of steroid therapy for higher risk patients with a poor prognosis (including 2 positive metanalyses and one negative). The current recommendations from gastroenterology society guidelines are:

Corticosteroids (preferably prednisolone) should be used in patients with severe alcoholic hepatitis in whom the diagnosis is certain. Severity is defined as a discriminant function > 32 and/or hepatic encephalopathy. The efficacy of steroids has not been adequately evaluated in patients with severe alcoholic hepatitis who also have concomitant pancreatitis, gastrointestinal bleeding, renal failure, and active infection.