1. Alcoholic Hepatitis (1)
C.L.I.P.S.
Patient Characteristics
Usually more than 100g alcohol intake daily. Often for more than 20 years, but can develop with much shorter history
Patients may have recently stopped drinking (usually due to illness) or increased drinking (often in response to social stressors)
Signs and Symptoms
Jaundice, anorexia, fever, RUQ pain, ascites or encephalopathy
May be found incidentally with minimal symptoms
Laboratory Analysis
AST/ALT elevation in 2:1 fashion, usually less than 300.
Elevated serum bilirubin (direct and indirect)
Elevated INR
Leukocytosis (sometimes extremely elevated leukemoid reaction). Infection must be ruled out before you can blame leukocytosis on hepatitis
Diagnosis
Above laboratory findings in setting of alcoholism
Rule out other causes of acute hepatitis
DF > 32 is severe alcoholic hepatitis --
Ddx for acute hepatitis:
-APAP toxicity
-NASH
-Viral Hepatitis
-Ischemic Hepatitis
-Budd-Chiari
-HELLP
-Wilson disease
-Autoimmune
-A1 antitrypsin deficiency
-Toxin induced (mushrooms)
Updated 5/17 P. Boyne

2. Alcoholic Hepatitis (2)
C.L.I.P.S.
Treatment
Non severe alcoholic hepatitis (DF<32). Alcohol abstinence and counseling and nutritional support
Severe alcoholic hepatitis (DF>32). Prednisolone 40mg daily for 28 days plus 2 week taper plus alcohol cessation and nutritional support.
Discontinue beta blockers if taking.
Lactulose if encephalopathic
If contraindications to steroids, can consider pentoxifylline (Trental) but recent large study showed this was no better than placebo
Liver transplant. Rarely done as AH implies recent alcohol use
Mortality
Non-severe AH: <10% 1 month mortality
Severe AH: 25-45% 1 month mortality
MELD >11 may be as effective as DF>32 at predicting mortality.
Lille score (performed on day 7 of therapy) may show response to glucocorticoids. Lille>0.45 suggests poor response to steroids and 75% 6 month mortality.
Lille score alone probably shouldn’t be used to discontinue treatment
Cause of death
Hepatic failure, GI bleeding, infection/sepsis, hepatorenal syndrome
Why is prednisolone preferred over prednisone?
This bypasses the “first-pass” hepatic metabolism in a poorly functioning liver where inactive prednisone is converted to active prednisolone