Recent advances in alcoholic hepatitis

Abstract

Alcoholic hepatitis (AH) is an acute deterioration in liver function seen in the context of prolonged excessive alcohol consumption and is characterised by the rapid onset of jaundice. The diagnosis of AH has been controversial for many years: it is now accepted that there are clear clinical criteria which can be used to diagnose AH without the need for a liver biopsy. Corticosteroids remain the only treatment proven to be effective in reducing short-term mortality in severe AH; abstinence from alcohol is the most important factor in determining long-term survival. It is recommended a trial of corticosteroid therapy is considered only in those patients with high baseline 'static' scores (Glasgow Alcoholic Hepatitis score and model for end-stage liver disease). Response to corticosteroid therapy should be assessed using a 'dynamic' score such as the Lille score at day 7, with corticosteroids continuing only in patients with a favourable score. Infection and acute kidney injury are associated with poorer outcomes in AH. Early screening for and treatment of infection is recommended with antibiotic therapy overlapping with any subsequent corticosteroid treatment. A biomarker which predicts benefit from corticosteroids at baseline would avoid a trial of therapy to determine response. More efficacious therapeutic options for AH patients are required with N-acetylcysteine, granulocyte colony stimulating factor, faecal microbiota transplantation and routine antibiotics showing promise, but adequate controlled trials are needed to confirm efficacy. Liver transplant has an emerging role for some patients with severe AH not responding to corticosteroids and is likely to become more acceptable with improved methods of patient selection.

Keywords: alcohol-induced injury; alcoholic liver disease.

Figure 1

Suggested treatment algorithm: all patients with alcoholic hepatitis should receive supportive care with appropriate management of alcohol withdrawal and general nutritional, as well as specific vitamin, support. A period of assessment to look for and treat infection is vital and this also allows disease trajectory to be determined: rapidly improving liver function suggests specific therapeutic intervention may not be necessary. A high ‘static’ score indicates potential benefit from corticosteroids although ‘response’ to these should be assessed after 7 days. ‘Responders’ continue treatment for 4 weeks; treatment is discontinued in ‘non-responders’. *European Association for the Study of the Liver guidelines (2018) also suggest corticosteroid treatment at a threshold of a modified discriminant function ≥32. GAHS: Glasgow Alcoholic Hepatitis score.