Ver el código de «Acute alcoholic hepatitis»

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==Background== <!--T:1-->

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Acute alcoholic hepatitis is inflammatory liver disease secondary to alcohol use.   
*Spectrum from hepatic steatosis to alcoholic hepatitis to [[Special:MyLanguage/cirrhosis|cirrhosis]]
*History of (usually chronic) [[Special:MyLanguage/alcohol Abuse|alcohol abuse]] (~80 grams of ethanol daily for 5 years)
*Ranges from subclinical cases to severe multisystem dysfunction


==Clinical Features== <!--T:3-->

<!--T:4-->
[[File:Jaundice08.jpg|thumb|Jaundice of the skin]]
[[File:SpiderAngioma.jpg|thumb|Spider angioma]]
[[File:Hepaticfailure.jpg|thumb|[[Special:MyLanguage/Ascites|Ascites]] secondary to cirrhosis.]]

===Symptoms=== <!--T:5-->

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*[[Special:MyLanguage/Abdominal pain|Abdominal pain]]
*[[Special:MyLanguage/Nausea and vomiting|Nausea and vomiting]]
*Weight loss / fatigue / anorexia


===Signs=== <!--T:7-->

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*[[Special:MyLanguage/RUQ tenderness|RUQ tenderness]]
*[[Special:MyLanguage/Jaundice|Jaundice]]
*[[Special:MyLanguage/Fever|Fever]]
*[[Special:MyLanguage/Hepatomegaly|Hepatomegaly]]
*[[Special:MyLanguage/Ascites|Ascites]]
*[[Special:MyLanguage/Encephalopathy|Encephalopathy]]
*Spider angioma
*[[Special:MyLanguage/GI bleed|GI bleed]]/varices
*[[Special:MyLanguage/Malnutrition|Malnutrition]] 
*Symptoms of [[Special:MyLanguage/alcohol withdrawal|alcohol withdrawal]]

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[[Special:MyLanguage/Cirrhosis|Cirrhosis]] is found in 50-60% of cases of alcoholic hepatitis<ref>Basra, Gurjot,et. al.  "Symptoms and Signs of Acute Alcoholic Hepatitis." World J Hepatol. 2011 May 27; 3(5): 118–120.</ref>


==Differential Diagnosis== <!--T:10-->

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*Alcoholic [[Special:MyLanguage/pancreatitis|pancreatitis]]
*[[Special:MyLanguage/Gallstones|Gallstones]]
*[[Special:MyLanguage/Budd-Chiari syndrome|Budd-Chiari syndrome]]
*[[Special:MyLanguage/Viral hepatitis|Viral hepatitis]]
*Drug-induced hepatitis
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{{Acute hepatitis causes}}
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==Evaluation== <!--T:12-->

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[[File:Auscities.png|thumb|Ascites appearance on ultrasound]]
[[File:CirrhosisWithAscitesMark.png|thumb|Liver cirrhosis with ascites on CT]]

===Work Up=== <!--T:14-->


====Labs==== <!--T:15-->

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*CBC
**[[Special:MyLanguage/Leukocytosis|Leukocytosis]] with elevated ANC 
*Chemistry including magnesium and phosphate
*[[Special:MyLanguage/LFTs|LFTs]]
**Very high elevations possibly more suggestive of viral or drug-induced hepatitis
**Elevated AST/ALT (characteristically >2:1 and < 500 IU/L)
**GGT alone is less reliable (low sensitivity and specificity)<ref>O'Shea RS, Dasarathy S, McCullough AJ (2010) Alcoholic liver disease. Hepatology 51: 307–328. doi: 10.1002/hep.23258</ref>
*Coagulation factors
**Elevated PT/INR
*Lipase if suspect [[Special:MyLanguage/pancreatitis|pancreatitis]]
*Consider [[Special:MyLanguage/viral hepatitis|viral hepatitis]] panel


====Imaging==== <!--T:17-->

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*Consider [[ultrasound: Abdomen|transabdominal ultrasound]] if concern for:
**[[Special:MyLanguage/biliary disease|Biliary obstruction]]
**[[Special:MyLanguage/Budd-Chiari syndrome|Budd-Chiari syndrome]] 
**Hepatic or biliary neoplasms


===Evaluation=== <!--T:19-->

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*Diagnosis is difficult and relies on a good history<ref>O'Shea RS, Dasarathy S, McCullough AJ (2010) Alcoholic liver disease. Hepatology 51: 307–328. doi: 10.1002/hep.23258</ref>
**History of significant alcohol intake
**Clinical evidence of liver disease
**Supporting laboratory abnormalities 
***May be nondiagnostic in patients with mild disease or early cirrhosis
*May also have electrolyte abnormalities from malnutrition or [[Special:MyLanguage/alcoholic ketoacidosis|alcoholic ketoacidosis]]


==Management== <!--T:21-->

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*Control of withdrawal symptoms
*Nutritional support for malnutrition: especially [[Special:MyLanguage/thiamine|thiamine]], [[Special:MyLanguage/folate|folate]], [[Special:MyLanguage/pyridoxine|pyridoxine]], [[Special:MyLanguage/magnesium|magnesium]], [[Special:MyLanguage/hypophosphatemia|phosphate]], [[Special:MyLanguage/dextrose|glucose]], and protein


===Severe Alcoholic Hepatitis=== <!--T:23-->

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*Defined as '''Maddrey's DF score ≥32'''<ref name=Singal2018>Singal AK, et. al. ACG clinical guideline: alcoholic liver disease. Am J Gastro. 2018; 113: 175-194.</ref>
**Confers mortality of 20-50% in 30 days
*1st line therapy: '''[[Special:MyLanguage/Prednisolone|Prednisolone]] 40mg PO qDay x4wks'''<ref name=Singal2018 />
**Must assess response to treatment at 7 days with Lille score
***If '''Lille score >0.45''', considered as non-responder and prednisolone should be discontinued<ref name=Singal2018 />
*[[Special:MyLanguage/Pentoxifylline|Pentoxifylline]] - evidence does not support its use<ref>Mathurin P, Louvet A, Duhamel A, et al. Prednisolone with vs without pentoxifylline and survival of patients with severe alcoholic hepatitis: a randomized clinical trial. JAMA. 2013;310(10):1033-41.</ref>
*Discontinue nonselective beta blockers (e.g., propranolol) to lower incidence of AKI<ref> Sersté T, Njimi H, Degré D, Deltenre P, Schreiber J, Lepida A, Trépo E, Gustot T, Moreno C. The use of beta-blockers is associated with the occurrence of acute kidney injury in severe alcoholic hepatitis. Liver Int. 2015 Aug;35(8):1974-82. doi: 10.1111/liv.12786. Epub 2015 Feb 4. PMID: 25611961.</ref>


==Disposition== <!--T:25-->


===Discharge=== <!--T:26-->

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*Mild disease/low risk
*Nutritional assessment and intervention
*Discuss [[Special:MyLanguage/alcohol|alcohol]] use and recommend strict abstinence


===Admit=== <!--T:28-->

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*High risk defined as MDF ≥ 32, MELD ≥ 18, or presence of [[Special:MyLanguage/hepatic encephalopathy|hepatic encephalopathy]]
*Admission should be considered for the above as well as any of the following complications:
**Evidence of active infection
**Renal failure
**Severe coagulopathy and/or liver failure
**Alcohol withdrawal/delirium tremens


==Prognosis== <!--T:30-->

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*Maddrey Discriminant Function score ([http://www.mdcalc.com/maddreys-discriminant-function-for-alcoholic-hepatitis/ MDF])
*Model for End-Stage Liver Disease score ([http://www.mdcalc.com/meld-score-model-for-end-stage-liver-disease-12-and-older/ MELD])
*High risk: MDF ≥ 32, MELD ≥ 18, or presence of [[Special:MyLanguage/hepatic encephalopathy|hepatic encephalopathy]]<ref>O'Shea RS, Dasarathy S, McCullough AJ (2010) Alcoholic liver disease. Hepatology 51: 307–328. doi: 10.1002/hep.23258</ref>


==See Also== <!--T:32-->

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*[[Special:MyLanguage/Acute hepatitis|Acute hepatitis]]
*[[Special:MyLanguage/Alcohol|Alcohol]]


==External Links== <!--T:34-->

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*http://www.aasld.org/sites/default/files/guideline_documents/AlcoholicLiverDisease1-2010.pdf


==References== <!--T:36-->

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<references/>

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[[Category:GI]]
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