Alcoholic hepatitis overview: Difference between revisions
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{{CMG}}; {{AE}} {{S.M}} | {{CMG}}; {{AE}} {{S.M}} | ||
==Overview== | ==Overview== | ||
[[Alcoholic hepatitis]] is caused be excessive consumption of [[alcohol]]. In US, 7.2% of adults suffer from [[alcohol use disorder]]. [[Symptoms]] of [[Alcoholic hepatitis]] may vary from [[mild]] to [[severe]]; therefore; any suspected patient should undergo [[liver function test]] and [[ultrasound]] to screen for [[Alcoholic hepatitis]]. [[Alcoholic hepatitis]] may progress to [[ hepatic steatonecrosis]],[[fibrosis]], [[cirrhosis]] or [[hepatocellular carcinoma]]. Consequently, all patients must be advised for [[alcohol]] abstinence. Additionally, [[nutritional supplements]] including [folic acid]], [[thiamine]], [[vitamin B6]], [[vitamin A]] and [[zinc]] can be provided. If [[Alcoholic hepatitis]] progress to [[cirrhosis]], [[liver transplant]] will be considered for treatment. | [[Alcoholic hepatitis]] is caused be excessive consumption of [[alcohol]]. In US, 7.2% of adults suffer from [[alcohol use disorder]]. [[Symptoms]] of [[Alcoholic hepatitis]] may vary from [[mild]] to [[severe]]; therefore; any suspected patient should undergo [[liver function test]] and [[ultrasound]] to screen for [[Alcoholic hepatitis]]. [[Alcoholic hepatitis]] may progress to [[ hepatic steatonecrosis]],[[fibrosis]], [[cirrhosis]] or [[hepatocellular carcinoma]]. Consequently, all patients must be advised for [[alcohol]] abstinence. Additionally, [[nutritional supplements]] including [[folic acid]], [[thiamine]], [[vitamin B6]], [[vitamin A]] and [[zinc]] can be provided. If [[Alcoholic hepatitis]] progress to [[cirrhosis]], [[liver transplant]] will be considered for treatment. | ||
==Historical Perspective== | ==Historical Perspective== | ||
[[Alcoholic hepatitis]] was first recognized in 1961 after investigation of 7 cases with excessive [[alcohol]] intake . Before the recognition of [[Alcoholic | [[Alcoholic hepatitis]] was first recognized in 1961 after investigation of 7 cases with excessive [[alcohol]] intake . Before the recognition of [[Alcoholic hepatitis]], it was believed that the [[symptoms]] are caused by [[malnutrition]] not due to toxic effects of [[alcohol]]. Charles S. Lieber developed modern research on alcohol-related [[liver disease]]. | ||
==Pathophysiology== | ==Pathophysiology== | ||
The [[pathophysiology]] of [[Alcoholic | The [[pathophysiology]] of [[Alcoholic hepatitis]] is caused by interplay between [[alcohol]] [[metabolism]], [[inflammation]] and [[innate]] [[immunity]]. [[Alcohol]] metabolism leads to depletion of [[ NAD]] and subsequent [[lipogenesis]]. Additionally, increased endotoxemia causes translocation of [[lipopolysaccharide]] from [[intestine]] to [[hepatocytes]]. In [[hepatocytes]], [[lipopolysaccharide]] activates [[kupffer cells]]. Therefore, activated [[cells]] release [[inflammatory]] markers which lead to [[Alcoholic hepatitis]]. | ||
== Causes== | == Causes== | ||
[[Alcohol]] is a significant cause of [[ Alcoholic hepatitis]]. Other factors that may associate with [[Alcoholic | [[Alcohol]] is a significant cause of [[ Alcoholic hepatitis]]. Other factors that may associate with [[Alcoholic hepatitis]] are [[hepatitis C]] and [[malnutrition]]. | ||
==Differentiating Alcoholic Hepatitis from other Diseases== | ==Differentiating Alcoholic Hepatitis from other Diseases== | ||
[[Alcoholic Hepatitis]] should be differentiated from [[viral hepatitis]], [[autoimmune hepatitis]], [[non-alcoholic fatty liver disease]], [[drug-induced liver injury]], [[Wilson disease]], [[cholestatic]] causes of [[liver disease]], and [[hepatocellular carcinoma]]. | [[Alcoholic Hepatitis]] should be differentiated from [[viral hepatitis]], [[autoimmune hepatitis]], [[non-alcoholic fatty liver disease]], [[drug-induced liver injury]], [[Wilson disease]], [[cholestatic]] causes of [[liver disease]], and [[hepatocellular carcinoma]]. | ||
==Epidemiology and Demographics== | ==Epidemiology and Demographics== | ||
In US, 7.2% of adults suffer from [[alcohol use disorder]].The peak [[incidence]] of [[Alcoholic | In US, 7.2% of adults suffer from [[alcohol use disorder]].The peak [[incidence]] of [[Alcoholic hepatitis]] is between 20-60 years of age.In 2007, [[Alcoholic hepatitis]] was accounted for 0.71% of all hospital admissions in US. Women are at greater risk of developing [[Alcoholic hepatitis]] after shorter duration and smaller amount of [[alcohol]] intake. | ||
==Risk Factors== | ==Risk Factors== | ||
The most common[[risk factors]] of developing [[Alcoholic | The most common[[risk factors]] of developing [[Alcoholic hepatitis]] include heavy [[alcohol]] intake, High [[body mass index]], [[Female]] gender , [[Malnutrition]] and [[hepatitis C]]. | ||
==Screening== | ==Screening== | ||
Patients with excessive [[alcohol]] intake requires screening for [[alcohol]] use with [[AUDIT]] questionnaire. If the score is above 8, [[Alcohol use disorder]] is diagnosed and patient requires further evaluation by performing [[liver]] test and [[liver]] [[ultrasound]]. | Patients with excessive [[alcohol]] intake requires screening for [[alcohol]] use with [[AUDIT]] questionnaire. If the score is above 8, [[Alcohol use disorder]] is diagnosed and patient requires further evaluation by performing [[liver]] test and [[liver]] [[ultrasound]]. | ||
==Natural history, Complications and Prognosis== | ==Natural history, Complications and Prognosis== | ||
[[Alcoholic]] [[liver disease]] may progress to [[fatty liver]] | [[Alcoholic]] [[liver disease]] may progress to [[fatty liver]], [[ hepatic]][[steatosis]], [[Alcoholic hepatitis]] or [[alcoholic]] [[steatonecrosis]],[[fibrosis]], [[cirrhosis]] and [[hepatocellular carcinoma]]. [[Complications]] of [[Alcoholic hepatitis]] include [[variceal [[hemorrhage]],[[hepatic]] [[encephalopathy]],[[ascites]],[[coagulopathy]], [[thrombocytopenia]],[[spontaneous bacterial peritonitis]], and [[iron]] overload. Different scoring systems were presented to predict the [[prognosis]] and [[mortality]] among patients with [[Alcoholic hepatitis]]. The most recent and accurate one is called Asymmetric dimethylarginine (ADMA) score. | ||
==Diagnosis== | ==Diagnosis== | ||
=== History and Symptoms=== | === History and Symptoms=== | ||
[[Alcoholic | [[Alcoholic hepatitis]] is suspected to occur in [[patients]] with excessive [[drinking]] over the [[decades]].[[Symptoms]] of [[Alcoholic hepatitis]] can vary from [[mild]] to [[severe]].The symptoms include [[nausea]],[[malaise]], low-grade [[fever]], [[abdominal Pain]], yellow discoloration of [[skin]] increased [[abdominal]] girth due to [[ascites]], [[gastrointestinal]] [[bleeding]] due to variceal [[hemorrhage]], [[lack of appetite]], [[confusion]], and [[lethargy]]. | ||
=== Physical Examination=== | === Physical Examination=== | ||
[[Physical examination]] findings | [[Physical examination]] findings include [[fever]], [[tachycardia]], [[tachypnea]],[[respiratory alkalosis]],[[hepatomegaly]],[[hepatic]] [[tenderness]] | ||
,[[scleral]] [[icterus]],[[splenomegaly]], [[ascites]],[[ssterixis]], darkening of the [[urine]], peripheral [[edema]],[[gynecomastia]],[[palmer]] [[erythema]],[[Spider angiomas]], altered [[hair]] distribution, [[Proximal]] [[muscle]] wasting. | ,[[scleral]] [[icterus]],[[splenomegaly]], [[ascites]],[[ssterixis]], darkening of the [[urine]], peripheral [[edema]],[[gynecomastia]],[[palmer]] [[erythema]],[[Spider angiomas]], altered [[hair]] distribution, [[Proximal]] [[muscle]] wasting. | ||
===Laboratory Findings=== | ===Laboratory Findings=== | ||
The most frequent [[laboratory findings]] of [[Alcoholic hepatitis]] include [[neutrophilic]] [[leukocytosis]] with [[bandemia]],[[anemia ]],[[AST]]/[[ALT]] [[ratio]] greater than 2, mild elevation of [[Alkaline Phosphatase]], [[hypoalbuminemia]], [[hyperbilirubinemia]],prolonged [[prothrombin time]], and elevated [[gamma-glutamyl transpeptidase]] level. | The most frequent [[laboratory findings]] of [[Alcoholic hepatitis]] include [[neutrophilic]] [[leukocytosis]] with [[bandemia]],[[anemia ]],[[AST]]/[[ALT]] [[ratio]] greater than 2, mild elevation of [[Alkaline Phosphatase]], [[hypoalbuminemia]], [[hyperbilirubinemia]],prolonged [[prothrombin time]], and elevated [[gamma-glutamyl transpeptidase]] level. | ||
=== X-Ray=== | === X-Ray=== | ||
There are no [[x-ray]] findings associated with [[Alcoholic | There are no [[x-ray]] findings associated with [[Alcoholic hepatitis]]. | ||
=== CT=== | === CT=== | ||
[[CT scan]] is usually performed among [[patients]] with [[Alcoholic | [[CT scan]] is usually performed among [[patients]] with [[Alcoholic hepatitis]] to exclude other abnormalities including [[neoplasm]], [[biliary]] [[obstruction]] or [[infiltrative]] [[liver]] [[disease]].[[CT scan]] can predict [[severity]] and [[outcome]] of [[Alcoholic hepatitis]] by presence of [[splenomegaly]], [[ascites]], [[varices]], [[liver]] length to mid [[clavicular]] line, decreased [[liver]] [[attenuation]], [[liver]] to [[spleen]] [[attenuation]] ratio and increased [[liver]] [[heterogenecity]]. | ||
=== MRI=== | === MRI=== | ||
[[MRI]] findings of [[Alcoholic | [[MRI]] findings of [[Alcoholic hepatitis]] are non-specific is usually done to exclude other [[etiologies]] and include [[hepatic]] [[steatosis]], increase T2 signal around [[portal]] [[system]], and Increased intensity in [[parenchymal]] signal. | ||
=== Ultrasound=== | === Ultrasound=== | ||
[[Ultrasound]] is the first choice of [[imaging]] test in [[Alcoholic | [[Ultrasound]] is the first choice of [[imaging]] test in [[Alcoholic hepatitis]]. The finding are [[hepatomegaly]],[[irregular]] outline of [[liver]] surface and edge [[nodularity]], diffuse hyper-echoic [[liver]],[[Atrophy]] of right lobe. Additionally, [[splenomegaly]], [[varices]] and [ascites]] are suggestive features of [[portal]] [[hypertension]]. | ||
=== Other Diagnostic Studies=== | === Other Diagnostic Studies=== | ||
[[Liver biopsy]] is indicated in patients whose [[diagnosis]] is uncertain and in patients with [[severe]] [[Alcoholic | [[Liver biopsy]] is indicated in patients whose [[diagnosis]] is uncertain and in patients with [[severe]] [[Alcoholic hepatitis]] who are probable to undergo medical treatment. [[Liver]] [[biopsy]] in [[Alcoholic Hepatitis]] include [[Polymorphonuclear cell|Polymorphonuclear]] infiltration, [[hepatic]] [[necrosis]], [[Mallory bodies]] in [[hepatocytes]], perivenular and perisinusoidal [[fibrosis]], ballooning [[hepatocytes]], and [[steatosis]]. | ||
==Treatment== | ==Treatment== | ||
===Medical Therapy=== | ===Medical Therapy=== | ||
All patients with [[Alcoholic Hepatitis]] must be advised to stopped [[alcohol]] use. Additionally, [[nutritional supplements]] including [folic acid]], [[thiamine]], [[vitamin B6]], [[vitamin A]] and [[zinc]] can be provided. [[Glucocorticoids]] is the most common pharmacologic treatment in [[Alcoholic | All patients with [[Alcoholic Hepatitis]] must be advised to stopped [[alcohol]] use. Additionally, [[nutritional supplements]] including [[folic acid]], [[thiamine]], [[vitamin B6]], [[vitamin A]] and [[zinc]] can be provided. [[Glucocorticoids]] is the most common pharmacologic treatment in [[Alcoholic hepatitis]] .[[Pentoxifylline]] can be used in patient with contraindication to [[steroids]]. | ||
=== Surgery=== | === Surgery=== | ||
[[Liver transplant]] is considered in case of [[cirrhosis]]. Orthotopic [[Liver transplantation|liver transplant]] is the definitive surgical treatment for [[hepatic failure]] associated with [[Alcoholic Hepatitis]]. Prior to [[liver transplant]], 6 months of [[abstinence]] is required. | [[Liver transplant]] is considered in case of [[cirrhosis]]. Orthotopic [[Liver transplantation|liver transplant]] is the definitive surgical treatment for [[hepatic failure]] associated with [[Alcoholic Hepatitis]]. Prior to [[liver transplant]], 6 months of [[abstinence]] is required. | ||
=== Primary Prevention=== | === Primary Prevention=== | ||
The [[primary prevention]] of [[Alcoholic | The [[primary prevention]] of [[Alcoholic hepatitis]] is [[alcohol]] abstinence.[[Alcohol]] abstinence improves [[histological]] features of [[hepatic]] injury and reduces [[portal hypertension]] and the risk of [[cirrhosis]]. Risk of [[recidivism]] is 67% to 81% after [[alcohol]] abstinence; therefore, combination [[psychotherapy]] with [[cognitive behavioral therapy]], peer driven support counseling, motivational enhancement therapy, and comprehensive medical care. | ||
=== Secondary Prevention=== | === Secondary Prevention=== | ||
[[Disulfiram]], [[naltrexone]], and [[ acamprosate]] are used to to maintain [[alcohol]] abstinence.Additionally, [[ | [[Disulfiram]], [[naltrexone]], and [[ acamprosate]] are used to to maintain [[alcohol]] abstinence.Additionally, [[baclofen]] and gamma hydroxyl butyrate are options to reduce recidivism in patients with advanced [[chronic liver disease]]. | ||
==References== | ==References== | ||
Latest revision as of 16:59, 2 August 2021
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Shadan Mehraban, M.D.[2]
Overview
Alcoholic hepatitis is caused be excessive consumption of alcohol. In US, 7.2% of adults suffer from alcohol use disorder. Symptoms of Alcoholic hepatitis may vary from mild to severe; therefore; any suspected patient should undergo liver function test and ultrasound to screen for Alcoholic hepatitis. Alcoholic hepatitis may progress to hepatic steatonecrosis,fibrosis, cirrhosis or hepatocellular carcinoma. Consequently, all patients must be advised for alcohol abstinence. Additionally, nutritional supplements including folic acid, thiamine, vitamin B6, vitamin A and zinc can be provided. If Alcoholic hepatitis progress to cirrhosis, liver transplant will be considered for treatment.
Historical Perspective
Alcoholic hepatitis was first recognized in 1961 after investigation of 7 cases with excessive alcohol intake . Before the recognition of Alcoholic hepatitis, it was believed that the symptoms are caused by malnutrition not due to toxic effects of alcohol. Charles S. Lieber developed modern research on alcohol-related liver disease.
Pathophysiology
The pathophysiology of Alcoholic hepatitis is caused by interplay between alcohol metabolism, inflammation and innate immunity. Alcohol metabolism leads to depletion of NAD and subsequent lipogenesis. Additionally, increased endotoxemia causes translocation of lipopolysaccharide from intestine to hepatocytes. In hepatocytes, lipopolysaccharide activates kupffer cells. Therefore, activated cells release inflammatory markers which lead to Alcoholic hepatitis.
Causes
Alcohol is a significant cause of Alcoholic hepatitis. Other factors that may associate with Alcoholic hepatitis are hepatitis C and malnutrition.
Differentiating Alcoholic Hepatitis from other Diseases
Alcoholic Hepatitis should be differentiated from viral hepatitis, autoimmune hepatitis, non-alcoholic fatty liver disease, drug-induced liver injury, Wilson disease, cholestatic causes of liver disease, and hepatocellular carcinoma.
Epidemiology and Demographics
In US, 7.2% of adults suffer from alcohol use disorder.The peak incidence of Alcoholic hepatitis is between 20-60 years of age.In 2007, Alcoholic hepatitis was accounted for 0.71% of all hospital admissions in US. Women are at greater risk of developing Alcoholic hepatitis after shorter duration and smaller amount of alcohol intake.
Risk Factors
The most commonrisk factors of developing Alcoholic hepatitis include heavy alcohol intake, High body mass index, Female gender , Malnutrition and hepatitis C.
Screening
Patients with excessive alcohol intake requires screening for alcohol use with AUDIT questionnaire. If the score is above 8, Alcohol use disorder is diagnosed and patient requires further evaluation by performing liver test and liver ultrasound.
Natural history, Complications and Prognosis
Alcoholic liver disease may progress to fatty liver, hepaticsteatosis, Alcoholic hepatitis or alcoholic steatonecrosis,fibrosis, cirrhosis and hepatocellular carcinoma. Complications of Alcoholic hepatitis include [[variceal hemorrhage,hepatic encephalopathy,ascites,coagulopathy, thrombocytopenia,spontaneous bacterial peritonitis, and iron overload. Different scoring systems were presented to predict the prognosis and mortality among patients with Alcoholic hepatitis. The most recent and accurate one is called Asymmetric dimethylarginine (ADMA) score.
Diagnosis
History and Symptoms
Alcoholic hepatitis is suspected to occur in patients with excessive drinking over the decades.Symptoms of Alcoholic hepatitis can vary from mild to severe.The symptoms include nausea,malaise, low-grade fever, abdominal Pain, yellow discoloration of skin increased abdominal girth due to ascites, gastrointestinal bleeding due to variceal hemorrhage, lack of appetite, confusion, and lethargy.
Physical Examination
Physical examination findings include fever, tachycardia, tachypnea,respiratory alkalosis,hepatomegaly,hepatic tenderness ,scleral icterus,splenomegaly, ascites,ssterixis, darkening of the urine, peripheral edema,gynecomastia,palmer erythema,Spider angiomas, altered hair distribution, Proximal muscle wasting.
Laboratory Findings
The most frequent laboratory findings of Alcoholic hepatitis include neutrophilic leukocytosis with bandemia,anemia ,AST/ALT ratio greater than 2, mild elevation of Alkaline Phosphatase, hypoalbuminemia, hyperbilirubinemia,prolonged prothrombin time, and elevated gamma-glutamyl transpeptidase level.
X-Ray
There are no x-ray findings associated with Alcoholic hepatitis.
CT
CT scan is usually performed among patients with Alcoholic hepatitis to exclude other abnormalities including neoplasm, biliary obstruction or infiltrative liver disease.CT scan can predict severity and outcome of Alcoholic hepatitis by presence of splenomegaly, ascites, varices, liver length to mid clavicular line, decreased liver attenuation, liver to spleen attenuation ratio and increased liver heterogenecity.
MRI
MRI findings of Alcoholic hepatitis are non-specific is usually done to exclude other etiologies and include hepatic steatosis, increase T2 signal around portal system, and Increased intensity in parenchymal signal.
Ultrasound
Ultrasound is the first choice of imaging test in Alcoholic hepatitis. The finding are hepatomegaly,irregular outline of liver surface and edge nodularity, diffuse hyper-echoic liver,Atrophy of right lobe. Additionally, splenomegaly, varices and [ascites]] are suggestive features of portal hypertension.
Other Diagnostic Studies
Liver biopsy is indicated in patients whose diagnosis is uncertain and in patients with severe Alcoholic hepatitis who are probable to undergo medical treatment. Liver biopsy in Alcoholic Hepatitis include Polymorphonuclear infiltration, hepatic necrosis, Mallory bodies in hepatocytes, perivenular and perisinusoidal fibrosis, ballooning hepatocytes, and steatosis.
Treatment
Medical Therapy
All patients with Alcoholic Hepatitis must be advised to stopped alcohol use. Additionally, nutritional supplements including folic acid, thiamine, vitamin B6, vitamin A and zinc can be provided. Glucocorticoids is the most common pharmacologic treatment in Alcoholic hepatitis .Pentoxifylline can be used in patient with contraindication to steroids.
Surgery
Liver transplant is considered in case of cirrhosis. Orthotopic liver transplant is the definitive surgical treatment for hepatic failure associated with Alcoholic Hepatitis. Prior to liver transplant, 6 months of abstinence is required.
Primary Prevention
The primary prevention of Alcoholic hepatitis is alcohol abstinence.Alcohol abstinence improves histological features of hepatic injury and reduces portal hypertension and the risk of cirrhosis. Risk of recidivism is 67% to 81% after alcohol abstinence; therefore, combination psychotherapy with cognitive behavioral therapy, peer driven support counseling, motivational enhancement therapy, and comprehensive medical care.
Secondary Prevention
Disulfiram, naltrexone, and acamprosate are used to to maintain alcohol abstinence.Additionally, baclofen and gamma hydroxyl butyrate are options to reduce recidivism in patients with advanced chronic liver disease.