Perspectives in clinical gastroenterology and hepatologyAlcoholic Hepatitis: Current Challenges and Future Directions
Section snippets
Diagnosis of Alcoholic Hepatitis
In the absence of confirmatory tests, eliciting an accurate history of alcohol use is one of the major challenges in diagnosing AH. In an obese patient who drinks excessively, when it is unclear whether the etiology is alcoholic steatohepatitis or nonalcoholic steatohepatitis, the alcohol–non-alcohol index (ANI) may be used to determine the etiology. The ANI uses body mass index, mean corpuscular volume, aspartate aminotransferase (AST)/alanine aminotransferase (ALT) ratio, and gender to
Abstinence From Alcohol
The major focus of attention is prevention of alcohol use. Abstinence is the most important factor in predicting long-term outcome of patients surviving the acute AH episode.39, 40 Evaluation by a team experienced in the treatment of alcoholism is recommended during the hospitalization for AH and is helpful in increasing abstinence rates after hospital discharge.41 Tools used to maintain abstinence from alcohol include motivational interviewing and cognitive behavioral therapy. Motivational
Corticosteroids
Corticosteroids are the most widely used agents for the treatment of severe AH. However, the 13 RCTs evaluating corticosteroids for treating AH reported during the past 40 years have shown mixed results.48 Meta-analysis of individual patient data from 5 RCTs that used corticosteroids for severe AH showed an approximately 50% relative survival benefit at 1 month (65% vs 85% survival among untreated vs treated), with the number needed to treat being 5 patients to reduce 1 death.49 Despite this
Liver Transplantation for Alcoholic Hepatitis
Controversy exists on use of LT for AH that relates to both medical and ethical issues.70 On the basis of a rationale that AH may improve with medical management and that duration of abstinence can predict abstinence after transplant, many transplant centers require a period of 6-month abstinence before considering transplant in patients with AH.71 However, data on 6-month pre-transplant abstinence and risk of relapse after LT are conflicting. In a pooled analysis of 32 studies, 6-month
Suggested Approach for Management of Alcoholic Hepatitis
A high index of suspicion is needed for diagnosis of AH among patients with chronic and active alcohol abuse and recent onset of jaundice (Figure 1). Diagnosis is often made clinically, and liver biopsy is recommended when clinical diagnosis is uncertain. Patients with mild disease are treated with nutritional supplementation, management of alcohol withdrawal, counseling for abstinence, and supportive care for liver disease complications. Patients with severe disease (mDF >32 or MELD ≥20)
Future Directions
Because of the current limitations and therapeutic options for patients with AH, there remains a critical need for newer, more effective agents for treating this condition. Until recently, there were scarce clinical resources from government or industry aimed at identifying new therapies for AH. However, more recently, a major initiative from the National Institute on Alcohol Abuse and Alcoholism has spearheaded large multi-institutional consortia with the task of identifying new therapeutic
Acknowledgments
Dr Singal's current affiliation is the Division of Gastroenterology and Hepatology, University of Alabama, Birmingham, Alabama.
References (91)
- et al.
Prediction of risk of liver disease by alcohol intake, sex, and age: a prospective population study
Hepatology
(1996) - et al.
Common polymorphism in the PNPLA3/adiponutrin gene confers higher risk of cirrhosis and liver damage in alcoholic liver disease
J Hepatol
(2011) - et al.
Risk factors of fibrosis in alcohol-induced liver disease
Hepatology
(2002) - et al.
Alcoholic hepatitis: prognostic models and treatment
Gastroenterol Clin N Am
(2011) - et al.
Utility of a new model to diagnose an alcohol basis for steatohepatitis
Gastroenterology
(2006) Alcoholic hepatitis
Clin Gastroenterol
(1981)- et al.
Pentoxifylline improves short-term survival in severe acute alcoholic hepatitis: a double-blind, placebo-controlled trial
Gastroenterology
(2000) Morphology of alcoholic liver disease
Clin Liv Dis
(2005)- et al.
Corticosteroid therapy of alcoholic hepatitis
Gastroenterology
(1978) - et al.
MELD score is a better prognostic model than Child-Turcotte-Pugh score or Discriminant Function score in patients with alcoholic hepatitis
J Hepatol
(2005)
Effectiveness and safety of baclofen for maintenance of alcohol abstinence in alcohol-dependent patients with liver cirrhosis: randomised, double-blind controlled study
Lancet
Nutrition in alcoholic liver disease
Clin Liv Dis
Normal protein diet for episodic hepatic encephalopathy: results of a randomized study
J Hepatol
Infection in patients with severe alcoholic hepatitis treated with steroids: early response to therapy is the key factor
Gastroenterology
Early switch to pentoxifylline in patients with severe alcoholic hepatitis is inefficient in non-responders to corticosteroids
J Hepatol
A randomized, double-blinded, placebo-controlled multicenter trial of etanercept in the treatment of alcoholic hepatitis
Gastroenterology
Alcoholic hepatitis: a clinician's guide
Clin Liv Dis
Extracorporeal liver support with molecular adsorbents recirculating system in patients with severe acute alcoholic hepatitis
J Hepatol
Albumin dialysis reduces portal pressure acutely in patients with severe alcoholic hepatitis
J Hepatol
The leaky gut of alcoholism: possible route of entry for toxic compounds
Lancet
Effect of probiotic treatment on deranged neutrophil function and cytokine responses in patients with compensated alcoholic cirrhosis
J Hepatol
Probiotics restore bowel flora and improve liver enzymes in human alcohol-induced liver injury: a pilot study
Alcohol
Hepatic expression of candidate genes in patients with alcoholic hepatitis: correlation with disease severity
Gastroenterology
Recombinant human interleukin-6: safety issues of a pleiotropic growth factor
Toxicology
Sterile inflammation in the liver
Gastroenterology
Liver related mortality in the US is underestimated
Hepatology
Epidemiology of alcoholic liver disease
Semin Liver Dis
Drinking habits as cofactors of risk for alcohol induced liver damage: the Dionysos Study Group
Gut
High blood alcohol levels in women: the role of decreased gastric alcohol dehydrogenase activity and first-pass metabolism
N Engl J Med
Mechanisms of synergy between alcohol and hepatitis C virus
J Clin Gastroenterol
Alcoholic hepatitis
N Engl J Med
Hepatitis C virus infection in alcoholic hepatitis: prevalence patterns and impact on in-hospital mortality
Eur J Gastroenterol Hepatol
Urinary ethyl glucuronide improves the detection of alcohol consumption in liver transplant candidates and recipients
Hepatology
Screening for alcohol consumption in patients after liver transplantation using determination of ethyl glucuronide in urine and hair
Hepatology
Ethyl glucuronide determination in hair for evaluation of long-term alcohol abstention in liver transplant candidates
Hepatology
Natural history of alcoholic hepatitis: I—the acute disease
Am J Dig Dis
Acute alcoholic hepatitis
J Clin Gastroenterol
Patients with severe alcoholic hepatitis and hepatorenal syndrome need new therapeutic strategy
Hepatology
Is histology required for the diagnosis of alcoholic hepatitis? A review of published randomised controlled trials
Gut
Development and validation of a novel histological classification with prognostic value for alcoholic hepatitis
Hepatology
Alcoholic liver disease
Hepatology
Utility of the Mayo End-Stage Liver Disease (MELD) score in assessing prognosis of patients with alcoholic hepatitis
BMC Gastroenterol
[Do MELD or Maddrey?: comparison of 2 forecasting models in patients with hepatitis toxic alcohol]
Revista de Gastroenterol de Mexico
MELD accurately predicts mortality in patients with alcoholic hepatitis
Hepatology
Prevalence of septic events, type 1 hepatorenal syndrome, and mortality in severe alcoholic hepatitis and utility of discriminant function and MELD score in predicting these adverse events
Dig Dis Sci
Cited by (128)
The role of neutrophils in alcohol-related hepatitis
2023, Journal of HepatologyPsychotherapy for Alcohol Use Disorder Is Associated With Reduced Risk of Incident Alcohol-Associated Liver Disease
2023, Clinical Gastroenterology and HepatologyCurrent and emerging therapies for alcohol-associated hepatitis
2023, Liver ResearchEmerging Pharmacotherapies in Alcohol-Associated Hepatitis
2023, Journal of Clinical and Experimental HepatologyCurrent Medical Treatment for Alcohol-Associated Liver Disease
2022, Journal of Clinical and Experimental HepatologyCitation Excerpt :Treatment regimens usually recommended by guidelines, prednisolone or prednisone 40 mg/d, is given orally for 28 days. Methylprednisolone is used in a dose of 32 mg given intravenously daily for patients unable to take medications orally.131,151,152,129 Additionally, the response to corticosteroid treatment can be predicted using the Lille model, where a value ≥ 0.45 predicts failure to corticosteroid treatment.
Conflicts of interest The authors disclose no conflicts.
This article has an accompanying continuing medical education activity on page e32. Learning Objectives—At the end of this activity, the successful learner will be able to identify pathogenic steps and associated treatment recommendations in patients with alcoholic hepatitis.