Today we reviewed a case of a middle aged gentleman with a long history of alcoholism who presented with diffuse abdominal pain and rectal bleeding and was found to have a direct bilirubin of nearly 30. We first went through the differential for direct hyperbilirubinemia, which can be placed in two broad categories, intrahepatic cholestasis & obstruction.
We reviewed the clinical manifestations of alcoholic hepatitis and were reminded that it is typically a patient with long-standing alcoholism who presents with jaundice, abdominal pain, direct hyperbilirubinemia, an AST:ALT typically ~300 or less in a 2:1 pattern, low albumin and sometimes fever/leukocytosis and no infectious etiology.
The diagnosis is a clinical one, and remember..obstruction must be considered. Infection is commonly present initially but can also develop later and one must also be hypervigilant about infection. We discussed the discriminant function score, which estimates the severity of alcoholic hepatitis once the diagnosis is made – a score of >32 predicts a high risk of mortality and steroid therapy may be useful. We reviewed the data briefly and made a case that it is uncertain whether it is useful, but it is certainly harmful in cases in which steroids are contraindicated, such as infection, active GIB, uncontrolled hyperglycemia, acute pancreatitis and psychosis.
If you and your team decide to use steroids, check a Lille Score at 7 days to determine if steroids are helping, and if you complete a 28 day course, make sure to taper the steroids afterwards.
As our GI fellow stated, what clearly shows a mortality benefit is alcohol cessation…use their admission as an opportunity to counsel them! The remainder of care is supportive, and should include attention to volume status, electrolyte repletion (remember K, Mg, Phos), nutrition (enteral preferred), and monitoring for the usual complications of cirrhosis. Lastly, nonselective beta blockers should be temporarily held in patients with severe AH until it resolves as it increases the risk of acute kidney injury.