alcohol-associated hepatitis
Contents
Acute jaundice in the setting of heavy alcohol use with a characteristic AST:ALT ratio ≥1.5–2:1 and both values <400 U/L. Severity determines management: MDF ≥32 or MELD >20 defines severe disease warranting prednisolone ± IV NAC. Reassess at day 4–7 with the Lille score — stop steroids if ≥0.45 (non-responder). Nutrition is as important as pharmacotherapy. Always rule out spontaneous bacterial peritonitis before starting steroids.
diagnosis
Clinical diagnosis — biopsy rarely needed unless presentation is atypical.
| criterion | threshold |
|---|---|
| onset of jaundice | within 60 days of heavy alcohol use |
| alcohol intake | >40 g/day (women), >60 g/day (men) for ≥6 months |
| AST | >50 U/L |
| AST:ALT ratio | ≥1.5–2:1 |
| both AST and ALT | <400 U/L |
| total bilirubin | >51 µmol/L |
Alcohol depletes hepatic pyridoxal-5’-phosphate (vitamin B6 cofactor for ALT) and causes mitochondrial injury preferentially releasing AST. If ALT exceeds AST, reconsider the diagnosis — think viral hepatitis, DILI, or MASLD with a superimposed insult.
what to rule out first
- Infection: diagnostic paracentesis if ascites present — steroids are contraindicated with active SBP
- Other liver injury: hepatitis B/C serologies, acetaminophen level, lipase, RUQ ultrasound (biliary obstruction, hepatic vein thrombosis)
- Sepsis workup: blood cultures, urine cultures, CXR
severity scoring
| score | severe threshold | use |
|---|---|---|
| Maddrey discriminant function (MDF) | ≥32 | traditional; identifies candidates for steroids |
| MELD | >20 | better validated for mortality prediction |
The original formula uses mg/dL — divide SI bilirubin (µmol/L) by 17.1 before plugging in.
Non-severe AH (MDF <32, MELD ≤20): supportive care, nutrition, alcohol cessation. No steroids.
management of severe AH
nutrition
Aggressive enteral nutrition is non-negotiable — malnutrition is universal and independently predicts mortality.
- 35 kcal/kg/day, 1.2–1.5 g/kg/day protein
- NG feeding if oral intake inadequate
- Do not restrict protein (encephalopathy in AH is driven by liver failure, not protein load)
pharmacotherapy
Prednisolone 40 mg PO daily × 28 days (or IV methylprednisolone 32 mg if unable to take PO)
- Use prednisolone (not prednisone) — does not require hepatic conversion
- ± IV N-acetylcysteine (NAC) for the first 5 days improves 1-month survival when combined with steroids (Nguyen-Khac, NEJM 2011)
- Active uncontrolled infection, sepsis, or SBP
- Active GI bleeding
- Severe AKI (creatinine >221 µmol/L in some protocols)
- HBV reactivation risk
Always tap the ascites before starting steroids. Treating SBP with steroids on board is a setup for septic death.
lille score — day 4–7 reassessment
Reassess steroid response using the Lille score (incorporates change in bilirubin from baseline):
| Lille score | interpretation | action |
|---|---|---|
| <0.16 | complete responder | continue prednisolone for full 28 days |
| 0.16–0.44 | partial responder | continue; benefit still likely |
| ≥0.45 | non-responder | stop steroids — continued exposure adds infection risk without survival benefit |
Non-responders with MELD ≥26 should be evaluated for early liver transplantation at centres with established protocols for selected patients.
what does not work
- Pentoxifylline — no mortality benefit (STOPAH, NEJM 2015)
- G-CSF — insufficient evidence; not recommended
- Prophylactic antibiotics — no proven role in the absence of documented infection
early liver transplantation
Historically, a 6-month abstinence rule excluded most severe AH patients from transplant. Multiple centres now offer early transplantation for steroid non-responders with:
- first liver-related decompensation
- supportive social environment
- no other severe psychiatric or substance use disorder
- formal psychosocial and addiction assessment
This remains centre-specific and not universally available in Canada.
common traps
- Starting steroids before ruling out infection — paracentesis and cultures first, always
- Using prednisone instead of prednisolone — in a failing liver, conversion is impaired
- Continuing steroids past day 7 in a non-responder — Lille ≥0.45 means stop; harm exceeds benefit
- Confusing AH with decompensated alcohol-related cirrhosis — AH is an acute inflammatory syndrome superimposed on (or triggering) liver failure; management differs from chronic decompensation
- Restricting protein for encephalopathy — worsens malnutrition and outcomes
related: approach to elevated liver enzymes · cirrhosis · decompensated cirrhosis · spontaneous bacterial peritonitis · hepatorenal syndrome