Alcoholic Hepatitis Management in the ED

By: Valeria Chew, MD

Pathogenesis

• Toxic metabolites in alcohol directly injure hepatocytes, inflammatory reaction results in further damage
• Not all heavy drinkers develop this (environmental? genetic?)

Symptoms

• Can develop in asymptomatic fatty liver disease patients if patient continues to drink
• Can be acute: Jaundice, abdominal distension, fever, GI bleed, altered mental status, tender hepatomegaly
• Can be gradual: anorexia, nausea, fever, dark urine, jaundice, weight loss, abdominal pain, and generalized weakness

Labwork

• ALT/AST usually between 300-500 with AST > ALT, commonly >1.5 ratio
• Elevated GGT
• Check electrolytes/Cr - derangements common in volume depletion/dehydration
• Ammonia - higher = poor prognosis
• PT-INR - synthetic function, higher = poor prognosis
• Albumin - lower = poor short term prognosis
• CBC - anemia suggestive of alcoholic hepatitis

Treatment

• Supportive care: fluids, antiemetics, analgesia, GI bleed prophylaxis
• Hypoglycemia common
• Watch the airway if they’re encephalopathic
• Potassium, Folate, Thiamine
• Encourage oral intake if able!

• Some may present in severe alcoholic hepatitis, cytokine storm with multiorgan system failure (ARDS, hepatorenal syndrome) with hypotension, fever, tachycardia without infectious source >>> Resuscitate, steroid course (40g x 28d), mechanical ventilation if needed

Going forward

• Avoid other hepatotoxins/further drinking
• Be aware of complications if/when they return: bleeding, withdrawal, infections, cirrhosis, hepatocellular carcinoma

Differential

• Malignancy, pancreatitis, biliary disease, autoimmune hepatitis, viral hepatitis, ingestion (acetaminophen, statins, some antibiotics, isoniazid), ischemic, HELLP, mushroom poisoning, Budd Chiari, carbon tetrachloride to name a few...

References

Hosseini, Nooshin et al. “Alcoholic Hepatitis: A Review.” Alcohol and alcoholism (Oxford, Oxfordshire) vol. 54,4 (2019): 408-416. doi:10.1093/alcalc/agz036

Oktay, Cem. "Jaundice, Hepatic Disorders, and Hepatic Failure." Tintinalli's Emergency Medicine Manual, 8e Eds. Rita K. Cydulka, et al. McGraw-Hill, 2017.