Alcohol Hepatitis

Alcoholic Hepatitis – Treatment Options

Introduction
Alcoholic hepatitis is an acute and often severe inflammatory condition of the liver caused by excessive and prolonged alcohol use. It is characterized by jaundice, hepatomegaly, fever, anorexia, and tender liver, often occurring after years of heavy drinking. Laboratory findings typically include elevated AST (usually <300 IU/L and AST/ALT ratio >2), hyperbilirubinemia, and prolonged INR. Severe alcoholic hepatitis carries a high short-term mortality risk, and treatment focuses on alcohol cessation, supportive care, and targeted therapies for severe disease.

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1. General and Supportive Measures

• Absolute alcohol abstinence: The most critical step in management; prevents further liver injury.

• Nutritional support:

  • High-protein, high-calorie diet (35–40 kcal/kg/day, 1.2–1.5 g protein/kg/day).

  • Oral or enteral feeding preferred; parenteral nutrition if oral not tolerated.

  • Supplement with thiamine, folate, vitamin B12, and multivitamins.

• Infection control: Prompt evaluation and treatment of infections (which are common and worsen prognosis).

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2. Corticosteroid Therapy

• Prednisolone (40 mg daily for 28 days) is recommended for severe alcoholic hepatitis.

• Severity assessed by Maddrey’s Discriminant Function (DF ≥32) or MELD score ≥21.

• Response assessment:

  • Lille score after 7 days of therapy predicts response.

  • Non-responders should discontinue steroids due to lack of benefit and infection risk.

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3. Alternative and Adjunctive Therapies

• Pentoxifylline (400 mg three times daily):

  • Previously used when steroids contraindicated (e.g., GI bleeding, renal failure, infection).

  • Evidence of benefit is weaker; less commonly used now.

• N-acetylcysteine (NAC):

  • Sometimes combined with corticosteroids for additional benefit (improved short-term survival).

• Biologics and targeted therapies: Still under investigation in clinical trials.

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4. Management of Complications

• Ascites: Sodium restriction, diuretics (spironolactone ± furosemide), paracentesis if tense ascites.

• Hepatic encephalopathy: Lactulose (first-line) ± rifaximin.

• Variceal bleeding: Endoscopic band ligation, beta-blockers (propranolol, nadolol) for prevention.

• Renal dysfunction/hepatorenal syndrome: Avoid nephrotoxic drugs; consider albumin, vasoconstrictors (terlipressin, norepinephrine).

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5. Liver Transplantation

• Considered in severe alcoholic hepatitis not responding to medical therapy (high Lille score, worsening MELD).

• Traditionally required 6 months of abstinence, but select centers now allow earlier transplant for carefully chosen patients.

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6. Long-Term Management

• Lifelong alcohol abstinence programs (counseling, behavioral therapy, addiction services).

• Management of chronic liver disease complications (cirrhosis surveillance, HCC screening).

• Integration with hepatology, psychiatry, and addiction medicine teams.