Alcoholic hepatitis
Hospitalist Best Practice
J Rush Pierce Jr, MD, MPH
Lenny Noronha, MD
September 11, 2013
Disclosures
• Financial: none
• Affiliations/biases
– I drink alcohol
– I have a close relative with alcoholism
– Evidence should inform our thinking
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Hospitalist Best Practice: Alcoholic hepatitis
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Roadmap for today
• Describe case
• Review recommended evaluation & treatment
• Review the role of MELD and Maddrey’s
discriminant calculations
• Review the literature regarding treatment
• Discuss discharge criteria
• Review the role of palliative care
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Hospitalist Best Practice: Alcoholic hepatitis
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Learning Objectives
1. List diagnostic criteria for alcoholic hepatitis.
2. Describe how to use an on-line calculator to
predict prognosis and treatment for patients
with alcoholic hepatitis.
3. List recommended treatments for alcoholic
hepatitis.
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Hospitalist Best Practice: Alcoholic hepatitis
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Case
• A 53 year-old man with a long history of daily
alcohol use presents with one week of
jaundice. BP = 95/60 mm Hg, P = 105/minute,
and T = 38.0C. Exam discloses icterus, ascites,
and an enlarged, tender liver. Bilirubin = 9
mg/dl, AST = 250 IU/dl, ALT = 115 IU/dl,
prothromin time = 22 secs, INR 2.7, creatinine
= 0.9 mg/dL, WBC = 15,000/cu mm with 70%
neutrophils. How should he be treated?
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Hospitalist Best Practice: Alcoholic hepatitis
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Questions you might have
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What is his diagnosis?
What evaluation should he have?
What is his prognosis?
How should he be treated?
Do we need to call GI?
How do we monitor his progress?
When can he leave the hospital?
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Hospitalist Best Practice: Alcoholic hepatitis
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What is his diagnosis?
• Regular, heavy alcohol consumption can be
associated with a variety of forms of liver
disease, including fatty liver, inflammation,
hepatic fibrosis and cirrhosis.
• The term alcoholic hepatitis describes a more
severe form of alcohol-related liver disease
associated with significant short-term
mortality.
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Hospitalist Best Practice: Alcoholic hepatitis
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Typical clinical and laboratory
features of alcoholic hepatitis
Feature
Criteria for alcoholic hepatitis
History
10 or more years of daily drinking, recent jaundice
Exam
jaundice, enlarged liver
Bilirubin
> 5 mg/dL
AST and ALT
both elevated but both < 400 IU/dL
AST/ALT ratio
>2
INR
elevated
Absolute neutrophil count
> 7,700 cells/cu mm
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Hospitalist Best Practice: Alcoholic hepatitis
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What evaluation should he have?
• Confirm the diagnosis
• Predict prognosis with MELD and Maddrey’s
• Infectious work-up
– ordering blood and urine cultures
– chest x-ray
– paracentesis to exclude SBP
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Hospitalist Best Practice: Alcoholic hepatitis
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Common scoring systems used in
management of alcoholic hepatitis
Scoring system
Data needed to
calculate
Use
Internet calculators
MELD –
Alcoholic
hepatitis
Bilirubin, creatinine,
INR
90-day prognosis
http://www.mayocl
inic.org/meld/may
omodel7.html
Maddrey’s
discriminant
function (mDF)
Protime, protime
control (13 at
UNMH), bilirubin
Consideration of
anti-inflammatory
treatment
http://www.mdcalc
.com/maddreysdiscriminantfunction-foralcoholic-hepatitis/
Lille Model
DOB, albumin,
creatinine , protime
at day 0; Bilirubin at
days 0 and 7
To judge response
to therapy, predict
6-month prognosis
after treatment
http://www.lillemo
del.com/score.asp
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Hospitalist Best Practice: Alcoholic hepatitis
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How should he be treated?
Treatment
Therapeutic options
Comments
Abstinence from alcohol
rehab programs, self-help
groups, acamposate,
baclofen, disulfiram,
naltrexone
Usually after discharge
Nutrition
Eating, tube feedings
Goal = 35 – 40 kcal/kg per
day
Corticosteroids
Prednisolone
40 mg daily for 28 days
followed by a 2 week taper
Phosphodiesterase
inhibitors
Pentoxifylline
400 mg TID for 28 days
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Hospitalist Best Practice: Alcoholic hepatitis
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Nutrition
• Enteral nutritional support was shown in a
multicenter observational study to be
associated with reduced infectious
complications and improved one year
mortality
• ACG recommends 35 – 40 kcal/kg per day and
protein intake 1.2 – 1.5g/kg per day. In the
average 70 kg patient this is 2,450 – 2,800
kcal/day
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Hospitalist Best Practice: Alcoholic hepatitis
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Corticosteroids
• Recommended by ACG for Maddrey’s > 32
• Cochrane 2008 review
– 15 trials with 721 randomized patients
– No overall mortality reduction
– Mortality reduced w/Maddrey’s > 32 & HE
• Another meta-analysis demonstrated a
mortality benefit when the largest studies
with 221 patients Maddrey’s >32 were
analyzed separately
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Hospitalist Best Practice: Alcoholic hepatitis
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Corticosteroids
• Prednisolone is preferred over prednisone
because it is the active drug.
• Concerns include hyperglycemia and
increased risk of infection.
• Contraindications
– active infection
– gastrointestinal bleeding
– acute pancreatitis
– renal failure.
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Hospitalist Best Practice: Alcoholic hepatitis
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Pentoxifylline
• Recommended by ACG if corticosteroids are
contraindicated
• A 2008 double-blind, placebo controlled trial
(n=101) demonstrated decreased 28-day
mortality (24.6% vs. 46% receiving placebo)
• Cochrane review of all studies concluded that
no firm conclusions could be drawn
• Small randomized trial (n= 68) showed
pentoxifylline superior to prednisolone
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Hospitalist Best Practice: Alcoholic hepatitis
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Pentoxifylline
• Can be prescribed to patients who have
contraindications to corticosteroid use
• Dose =400 mg TID for four weeks.
• Common side effects are nausea & vomiting
• Cannot be administered by NG tube
• Should not be used in patients with recent
cerebral or retinal hemorrhage.
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Hospitalist Best Practice: Alcoholic hepatitis
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DC Med Costs
Prednisolone 40mg daily
UNM Cost
UNM Care Co-pay
Self Pay
$1.50
$7
$10
$8
$7
$100
#21 (3wks)
Pentoxifylline 400mg tid
#84 (4 wks)
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Hospitalist Best Practice: Alcoholic hepatitis
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Prognosis
• Case patient MELD = 26
– Confers 43% - 3 month mortality
• Higher if HE or ascites present
– High probability to have cirrhosis if he does
survive episode of AAH
• How should you tell this to patient/family?
• What considerations follow in this regard?
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Hospitalist Best Practice: Alcoholic hepatitis
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Lille Model
Louvet. Hepatology 2007;45:1348
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Alcoholic liver disease: proposed recommendations for the American College of Gastroenterology
Arthur J McCullough and J F Barry O' Connor, Am J Gastr, 1998, 93, 2022-2036.
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Brief Report on UNMH ‘10-’12
180
171
Total 467 pts
107 Readmissions
167
160
140
120
117
100
Unique Patients
Readmissions
80
60
40
31
28
16
20
0
2010
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2012
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UNMH AAH ‘10-’12 cont’d
• 33 initially adm to MICU
• 143 spent time in MICU during admission
• Median age 45
• 49 died in hospital
– Another 33 reported deaths within 90 days of dc
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UNMH AAH ‘10-’12 Dispo*
Discharged Home
Expired
To Skilled Nursing Facility
Left Against Medical Advice
To Non-Medical Facility
Hospice (Cont Care)
Rehab
To Hospital
*based on dc order
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Hospitalist Best Practice: Alcoholic hepatitis
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Great reasons to consult Palliative
• High mortality condition in young people
– Assess understanding of diagnosis/prognosis
– Family support
– Reinforce your team’s communication (i.e. NG
feeds, transplant candidacy, DC)
– Support your team
– Continuity for pt during long hospitalization
• Ward team handoff/ICU transfer
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Hospitalist Best Practice: Alcoholic hepatitis
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Early Consultation Preferred!
• All patients c AAH, DF > 32
• Please consult as soon as diagnosis suspected
– Time to establish rapport
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Hospitalist Best Practice: Alcoholic hepatitis
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Palliative Care Consultation
• Goals of Care
• Advance Care Planning
– Describe dispo options (i.e. SNF, NH, home)
– ICU transfer, rehospitalization?
– Surrogate decision maker
• Documentation
• Guidance to clarify wishes
– Code status
• Patient advocacy
• Assess spiritual care needs
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Hospitalist Best Practice: Alcoholic hepatitis
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Discharge considerations
• No clinical trials have studied optimal timing
of discharge. Expert opinion based on clinical
experience recommends that patients be kept
in the hospital until they are eating, signs of
alcohol withdrawal and encephalopathy are
absent, and bilirubin is less than 10 mg/dl
• Attention to abstinence from EtOH is
paramount
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Hospitalist Best Practice: Alcoholic hepatitis
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Alcoholic hepatitis - approach
1.
2.
3.
4.
Determine that pt fits the clinical picture
Admit and cessation of alcohol
Order folate, thiamine, MVI, and vitamin K.
Add a note about potential withdrawal to
hand-off report.
5. Order an infectious work-up (blood and urine
cultures, CXR, and paracentesis).
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Hospitalist Best Practice: Alcoholic hepatitis
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Alcoholic hepatitis - approach
6. Dietary consult for calorie counts,
importance of > 2,500 cals/day.
7. Consider tube feedings if not meeting goal
8. Determine Maddrey’s and MELD scores
9. Order prednisolone 40 mg daily; if actively
bleeding or infected, Trental 400 mg TID
10. Determine Lille score treatment day 7
11. Discuss code status and end-of life issues
12. Consider GI consult
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Hospitalist Best Practice: Alcoholic hepatitis
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Alcoholic hepatitis – areas of
possible consensus
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Use of NG feedings for nutrition
When to call GI
When to call palliative care
Evaluation of afebrile leukocytosis
Discharge criteria
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