• Upper GI Bleed = Proximal to ligament of Treitz (suspensory muscle that holds the duodenum)
• Lower GI Bleed = Distal to ligament of Treitz

• Factors most predictive of an upper GI source
  • Hx of Melena
    • Hematochezia is usually due to lower GI Bleed, But it can still occur with massive upper GI bleeding!
  • Coffee ground emesis
  • Ratio BUN:Cr >30

• Risk Factors
  • Mean intake of 100g/day for 10-20 years
    • Standard drink of ETOH = 14g pure alcohol
      • 12oz beer
      • 5oz wine
      • 5 oz of 80 proof liquor (“Shot”)
  • Binge drinking
    • Men = 5 drinks in 1 sitting
    • Women = 4 drinks
• Pathophysiology
  • Standard alcohol metabolism in cells
    • Alcohol dehydrogenase (ADH) plus cytochrome P-450 2E1 (CYP2E1) convert ethanol into acetaldehyde which is then converted to acetate
    • CYP2E1 releases reactive oxygen species leading to inflammation
    • NAD+ is used as oxidizing agent for ADH and is converted to NADH
      • Excess alcohol creates an imbalance of NAD/NADH
      • Excess NADH decreases oxidation of fatty acid oxidation
    • While acetate increases fatty acid synthesis
      • Both leading to steatosis
• Presentation
  • Pts often present between 40-50 years of age
  • Classic presenting features
    • Jaundice
    • Scleral icterus
    • Anorexia
    • Fever
    • Tender RUQ
    • Hepatomegaly
    • Abdominal distention due to ascites
    • Hepatic encephalopathy
    • Bruit can be appreciated over the liver due to increased hepatic blood flow

Labs

• LFTs
  • Moderate elevations of AST and ALT
    • Usually less than 300, rarely higher than 500
    • AST:ALT ratio >2
      • ALT is less due to alcohol induced deficiency of Pyridoxal 5-phosphate, which is a coenzyme of ALT. Thus the ratio reflects the failure to appropriately increase the ALT, rather than an inappropriate increase in AST.
    • Elevated Tbili and Dbili
• CBC
  • Leukocytosis (usually <20) with a neutrophil predominance
    • Extreme Leukemoid reaction (>50) is associated with a very poor prognosis.
  • Macrocytosis
    • Reflective of poor nutritional status
  • Thrombocytopenia
• • Coags
    • Elevated INR
• Imaging (show pics!)
  • 1^st choice: Abdominal ultrasound
    • It’s quick, easy, and relatively cheap
    • Will help rule out Budd-Chiari, abscess, obstruction, or neoplasm
    • Will show fatty changes in liver vs underlying cirrhosis

• Maddrey Discriminant Function
  • DF >32 signifies severe alc hep and is associated with high short-term mortality
    • May benefit from glucocorticoid therapy
• Treatment
  • 3 main things
    • Alcohol cessation
    • Nutritional support
    • Steroids
      • Contraindicated for:
        • GI Bleed
        • Infection
        • Renal failure
        • Pancreatitis
      • Check Lille Score on day 7 to evaluate response
        • >.45 is associated with 6-month survival of 25% –> ok to stop steroids
        • <.45 is associated with 85% survival
  • Pentoxyfilline –> little evidence!
    • The Steroids or Pentoxifylline for Alcoholic Hepatitis (STOPAH) trial was just published in the New England Journal in 2015.
      • They found a significant 28 day mortality benefit for prednisolone with an odds ratio of .61.
        • However, the mortality benefit was lost at 90 days and 1 year
      • On the other hand, pentoxifylline did not improve survival compared to placebo