A prognostic evaluation and management of alcoholic hepatitis

Abstract

Alcoholic hepatitis (AH) is an acute and severe form of alco1holic liver disease associated with high morbidity and mortality of 30-50% worldwide, severity ranging from asymptomatic derangement of liver biochemistries to fulminant liver failure or death. Rapidly progressing jaundice and coagulopathy in prolonged excessive alcohol abusers with or without fever, malnutrition, and tender liver are the clinical hallmarks. The prognostic models (Model for end-stage liver disease, Maddrey's discriminant function [MDF], age, serum bilirubin, INR, creatinine [ABIC], Glasgow Alcoholic Hepatitis Score [GAHS], Lille's Score) not only predict the short term mortality, but also guide the clinicians to choose appropriate specific therapy (corticosteroid or pentoxifylline) and as a stopping rule if there is no significant benefits of it. MDF Score is commonly followed in clinical practice, score of >32 would predict short term mortality of around 20-30% at 1 month and 30-40% within 6 months after presentation. The GAHS on day 1 can predict 28 day overall survival outcome accuracy of 81%, which is comparatively higher than MDF Score. Moreover, ABIC Score categorizes risk of deaths (based on 90 days) into low risks (0%), intermediate risk (30%), and high risk (75%). Corticosteroid and pentoxifylline have significant benefits in decreasing mortality (corticosteroid improves survival on 28 day and 84 day of 78% and 59%) in severe disease state (MDF >32 or Lille's Score >0.45 or GAHS >9). Corticosteroid is the initial treatment of choice with infections screening before initiating; however, pentoxifylline is better preferred in case of AH with severe infections and hepatorenal syndrome. Additionally, combination of corticosteroids and N-acetylcysteine decreases development of hepatorenal syndrome, infections, and short-term mortality. However, the Lille Score after corticosteroid therapy of >0.45 after day 7 indicates poor responders or >0.56 indicates null responders. Therefore, in these cases, either therapy has to be stopped or changed to pentoxifylline. In treatment failure cases, liver transplantation is the ultimate option. However, the facilitating of this service in most transplant centers is a challenge. Beside these specific therapies, alcohol abstinence and recommendation of nutritional supplements with high calorie, protein diet and vitamin E, C, thiamine regardless of other treatment plays a prime role in preventing disease progression and survival benefits even in pre and post-transplant cases.