Critically ill pts with alcoholic hepatitis have 30-day mortality rates >50%. Severe alcoholic hepatitis characterized by PT >5 × above control, bilirubin >137 µmol/L (>8 mg/dL), hypoalbuminemia, azotemia. A discriminant function can be calculated as 4.6 × (pt's PT in seconds) (control PT in seconds) + serum bilirubin (mg/dL). Values ≥32 are associated with poor prognosis. A Model for End-Stage Liver Disease (MELD) score > 21 is also associated with significant mortality in alcoholic hepatitis. Ascites, variceal hemorrhage, encephalopathy, hepatorenal syndrome predict a poor prognosis.
Treatment: Alcoholic Liver Disease Abstinence is essential; 8500- to 12,500-kJ (2000- to 3000-kcal) diet with 1 g/kg protein (less if encephalopathy). Daily multivitamin, thiamine 100 mg, folic acid 1 mg. Correct potassium, magnesium, and phosphate deficiencies. Transfusions of packed red cells, plasma as necessary. Monitor glucose (hypoglycemia in severe liver disease). Pts with severe alcoholic hepatitis defined as a discriminant function >32 or MELD >20 should be given prednisone 40 mg/d or prednisolone 32 mg/d PO for 4 weeks followed by a taper. Pentoxifylline demonstrated improved survival, primarily due to a decrease in hepatorenal syndrome and led to the inclusion of this agent as an alternative to glucocorticoids in the treatment of severe alcoholic hepatitis. Liver transplantation may be an option in carefully selected pts with end-stage cirrhosis. |