Hepatitis-Alcoholic
Adult-Gerontology Acute Care Practice Guidelines
Definition
A.Syndrome of progressive inflammatory liver injury associated with long-term heavy intake of alcohol.
B.Alcohol abuse is the most common cause of serious liver disease in Western society.
Incidence
A.In the United States, alcoholic liver disease affects more than 2 million people.
B.The true prevalence of alcoholic hepatitis is unknown as the patient may be asymptomatic or never seek medical attention.
Pathogenesis
A.Although the pathogenesis is not known, genetic, environmental, nutritional, metabolic, and immunologic factors may play a role.
Predisposing Factors
A.Majority of patients have a history of heavy alcohol use for two or more decades. Heavy is defined as greater than 100 g per day.
B.Women are more susceptible than men.
C.Peak age is 40 to 50 years old.
D.Alcoholic liver disease is more common in minority groups, particularly among Native Americans.
Subjective Data
A.Common complaints/symptoms.
1.Anorexia.
2.Fever.
3.Right upper quadrant (RUQ) pain.
4.Abdominal distension.
5.Dark urine.
6.Clay-colored stools.
B.Common/typical scenario.
1.History of daily alcohol use.
2.Stressful life events may trigger an increase in intake.
3.It is common for patients to cease alcohol intake several weeks prior to presentation due to feeling more ill.
C.Family and social history.
1.It is essential that the healthcare provider take a careful alcohol history.
2.May need to elicit a more accurate history by including family members.
3.Drinking patterns may vary. Heavy drinking can be intermittent (e.g., weekends only) or hidden from family members.
4.A standard drink is defined as 14 g of alcohol. Examples include:
a.12 ounces of beer.
b.5 ounces of wine.
c.1.5 ounces of distilled spirits.
d.8 to 9 ounces of malt liquor.
D.Review of systems.
1.Cognitive changes (encephalopathy).
2.Jaundice.
3.Anorexia.
4.Fever.
5.RUQ/epigastric pain.
6.Abdominal distension.
Physical Examination
A.Temporal wasting.
B.Scleral icterus.
C.Generalized jaundice.
D.Hepatomegaly.
E.Ascites.
F.Spider angiomata, palmar erythema, and gynecomastia suggest advanced disease.
G.Lower extremity edema.
Diagnostic Tests
A.Lab tests.
1.Hepatic function panel: Aspartate aminotransferase (AST)/alanine aminotransferase (ALT) ratio is 2:1.
2.Complete blood count (CBC): Elevated white blood cell (WBC).
3.International normalized ratio (INR): Elevated.
4.Testing for hepatitis A, B, and C; autoimmune markers (antinuclear antibody [ANA], AMA, ASMA, LKM1).
B.Imaging.
1.Abdominal ultrasound with Dopplers to rule out biliary obstruction, Budd–Chiari malformation, or cirrhosis.
C.Liver biopsy.
D.If labs and imaging are nondiagnostic, biopsy may be considered.
Differential Diagnosis
A.Acute viral hepatitis.
B.Autoimmune hepatitis.
C.Drug-induced liver injury (DILI).
D.Shock liver.
E.Ischemic hepatitis.
F.Budd–Chiari.
G.Wilson’s disease.
H.Alpha 1 antitrypsin deficiency.
I.Toxin-induced hepatitis (e.g., mushroom poisoning).
Evaluation and Management Plan
A.General plan.
1.Admission to ICU in patients that are unstable, that is, encephalopathic.
2.Fluid management and nutritional support.
3.Acuity of illness based on Maddrey Discriminant Function (DF) score and need for glucocorticoid therapy. DF is a calculation using bilirubin and prothrombin time (PT).
4.Alcohol withdrawal protocol per institutional guidelines.
5.Infectious workup to rule out other causes of mental status change.
6.Prophylaxis against gastrointestinal (GI) bleeding.
B.Patient/family teaching points.
1.Referral for substance abuse counseling.
2.Length of sobriety to meet transplant candidacy requirement per institution policy.
3.Steroid tapering schedule.
C.Pharmacotherapy.
1.GI prophylaxis: Proton pump inhibitors (PPI) or H2 blocker.
2.Stop nonselective beta blocker during acute crisis due to risk of acute kidney injury (AKI). May resume later.
3.Nutritional support: Adequate calories and protein; vitamins thiamine, folate.
4.Glucocorticoids.
a.Severe cases with DF greater than 32 receive prednisone/prednisolone for 28 days.
b.Discontinue if no improvement after 7 days. This is based on the Lille score, a predictor of response to steroid treatment.
5.Lactulose or trial of xifaxan therapy for encephalopathy.
D.Discharge instructions.
1.Review tapering schedule of steroids if applicable.
2.Set up outpatient substance abuse counseling or inpatient rehab.
3.Repeat lab tests in 1 week.
4.Close follow-up with hepatologist.
Follow-Up
A.As per discharge instructions, close follow-up with hepatologist and transplant center, if appropriate.
Consultation/Referral
A.Psychiatry: Addiction specialist.
B.Transplant center.
Special/Geriatric Considerations
A.Hemolysis, elevated liver enzymes, low platelet count in the setting of pregnancy (HELLP).
Bibliography
Friedman, S. L. (2018, August 13). Alcoholic hepatitis: Clinical manifestations and diagnosis. In K. M. Robson (Ed.), UpToDate. Retrieved from https://www.uptodate.com/contents/alcoholic-hepatitis-clinical-manifestations-and-diagnosis
Friedman, S. L. (2018, August 28). Management and prognosis of alcoholic hepatitis. In K. M. Robson (Ed.), UpToDate. Retrieved from https://www.uptodate.com/contents/management-and-prognosis-of-alcoholic-hepatitis
Heuman, D. M. (2016). Alcoholic hepatitis: Overview. In B. S. Anand (Ed.), Medscape. Retrieved from https://emedicine.medscape.com/article/170539-overview
National Institute on Alcohol Abuse and Alcoholism. (n.d.). What is a standard drink? Retrieved from https://www.niAAA.nih.gov/alcohol-health/overview-alcohol-consumption/what-standard-drink