What is Alcoholic Hepatitis (Alcohol-related Liver Damage)?
Drinking too much alcohol can lead to various liver diseases like fatty liver disease, alcoholic hepatitis or, over time, cirrhosis. Alcoholic hepatitis is a serious type of liver disease that arises quickly, causing symptoms such as jaundice (yellowing of the skin and eyes), general discomfort, swelling in the liver area, and signs of inflammation throughout the body. The recent increase in hospitalizations related to alcoholic hepatitis in the U.S. highlights the significance of this disease and the importance of its management.
If a person with alcoholic hepatitis continues to drink, the disease is likely to progress to cirrhosis. But, if they stop drinking, the inflammation from hepatitis can return to normal in a few months. However, any cirrhosis that has already developed is irreversible and cannot be reversed.
What Causes Alcoholic Hepatitis (Alcohol-related Liver Damage)?
The National Institute on Alcohol Abuse and Alcoholism (NIAAA) and Alcoholic Hepatitis Consortia provides guidelines for defining alcoholic hepatitis. They explain it as a condition which includes:
• The appearance of jaundice (a yellowing of the skin or eyes) within 60 days of heavy alcohol consumption (more than about four drinks a day) for at least 6 months
• A particular blood test result (serum bilirubin) more than 3 mg/dL
• Increased liver enzyme levels (aspartate aminotransferase or AST) between 50 U/L to 400 U/L
• A ratio of more than 1.5 when comparing levels of AST and another liver enzyme (ALT)
• Rule out other causes of acute hepatitis
It’s key to know the difference between two forms of liver disease related to alcohol: alcoholic steatohepatitis (ASH) and alcoholic hepatitis (AH). Around 20% to 40% of heavy drinkers with fatty liver disease will develop liver inflammation, known as ASH. The confirmation of ASH is based on examining liver tissue, whereas AH is identified through clinical evaluation. Key features of ASH include fat build-up in the liver, liver cell swelling, and certain changes in liver tissue. On the other hand, AH is associated with symptoms such as a history of heavy drinking, jaundice, fever, rapid heart rate, fast breathing, enlarged liver, an increase in white blood cells, and particular liver enzyme levels.
Although the amount of alcohol drunk is a key risk factor for developing chronic liver disease, the progression of the disease isn’t directly related to the quantity of alcohol consumed. Even shorter periods of heavy drinking can lead to AH. Typically, patients with AH are between 40 to 60 years old, have consumed a large amount of alcohol daily for a decade and have no other cause of acute hepatitis. Other risk factors include having a high body mass index (BMI), being female, and carrying a specific gene variant called PNPLA3. Yellowing of the skin or eyes is a sign of poor prognosis. Acute bouts of heavy drinking in patients who already drink heavily and chronically is likely the trigger for AH.
Risk Factors and Frequency for Alcoholic Hepatitis (Alcohol-related Liver Damage)
About two-thirds of adults in the United States consume alcohol, and about 7.2% struggle with alcohol use disorder (AUD). Drinking too much alcohol is the third most preventable cause of death in the country. A decade-long study from 2001 to 2011 conducted across 211 hospitals showed that around 0.08% to 0.09% of hospital admissions were due to alcoholic hepatitis, a liver condition caused by alcohol abuse.
Signs and Symptoms of Alcoholic Hepatitis (Alcohol-related Liver Damage)
Some people with mild symptoms of alcoholic liver disease might have a fever, pain or discomfort in the upper right part of their stomach, and higher levels of certain liver enzymes in their blood test results, which return to normal levels when the person stops drinking alcohol. On the other hand, severe symptoms might include yellowing of the skin and eyes (jaundice), fluid buildup in the abdomen (ascites), problems with brain function caused by the liver (hepatic encephalopathy), and issues with blood clotting (coagulopathy).
During a physical examination, doctors may detect faster than normal heart rate (tachycardia), rapid breathing (tachypnea), a fever, an enlarged liver, and signs of high blood pressure in the vein that supplies blood to the liver (portal hypertension). Additional signs in people with severe liver scarring, or cirrhosis, can include spider-like blood vessels showing through the skin (spider angiomas), loss of muscle tissue in the upper part of the arms and legs (proximal muscle wasting), and the development of male breast tissue (gynecomastia).
Testing for Alcoholic Hepatitis (Alcohol-related Liver Damage)
Diagnosing alcoholic hepatitis usually involves a mix of clinical analysis supported by lab findings. Everyone suspected of having this condition should undergo imaging tests to rule out diseases such as liver abscess, liver cancer, and biliary obstruction.
Your liver tests might reveal a high level of AST, an enzyme found in your liver, while the ALT enzyme is usually within the regular range. This situation is quite different from other liver-related conditions. Your doctor may also use the Carbohydrate-deficient transferrin test, which is typically reliable in identifying long-term heavy drinking.
Ultrasound, which is an imaging test that uses sound waves, is the initial go-to test to examine patients with suspected alcoholic hepatitis. It’s helpful in ruling out issues like gallstones and other problems related to the bile ducts. A liver biopsy, which involves taking a small sample of your liver tissue for analysis, can be beneficial in ruling out other disorders. But it should be performed with caution, given that patients with alcoholic hepatitis often have blood clotting disorders and low platelet counts.
There are several ways to gauge the severity of alcoholic hepatitis and determine who might gain from medication. Some available methods include the Maddrey Discriminant Factor and others that look at a mix of elements like age, bilirubin levels, the international normalized ratio, creatinine score, blood urea nitrogen, and the count of white blood cells. Notably, the Lille score calculates data from the start and end of the first week of steroid therapy to assess the response and further need for treatment. It’s also recently been suggested that a scoring system based on a biopsy might be useful for predicting how the disease is likely to progress in patients with alcoholic hepatitis.
Recent research suggests that C-reactive protein, a substance produced by the liver in response to inflammation, could serve as a good indicator of alcoholic hepatitis.
Treatment Options for Alcoholic Hepatitis (Alcohol-related Liver Damage)
Avoiding alcohol and getting enough nutrients are critical steps in managing patients with alcoholic hepatitis. Specialist help is often needed to assist with maintaining sobriety. Up to 20% of these patients might develop cirrhosis, a severe scarring of the liver, each year, and 10% may experience liver healing with alcohol abstinence.
Patients with alcoholic hepatitis are categorized as having either mild-moderate or severe forms of the disease. Scoring measures like MDF, MELD, ABIC, or Glasgow AH are used to determine the severity of the disease and predict the mortality risk. Patients with severe forms of alcoholic hepatitis may be treated with a short course of the steroid prednisolone. If patients can’t take prednisolone orally, methylprednisolone is an intravenous alternative. The use of these steroids should be carefully evaluated after seven days as failure to respond may necessitate discontinuation. If a patient responds, treatment continues for another three weeks.
Use of steroids is not advised if patients also have active gastrointestinal bleeding, severe pancreatitis, uncontrolled diabetes, active infection, or kidney failure. Alternatives, like pentoxifylline, may be used in these cases. People with bacterial infection can be treated with steroids only after the infection is controlled with antibiotics thankfully to an anti-inflammatory effect of steroids.
However, recent studies, including the STOPAH trial, show that steroid and Pentoxifylline treatment only improves short-term mortality rates without significant difference at the 6-month or 1-year mark. The use of Anti-TNF (tumor necrosis factor) agents has shown no proven survival benefits and may even increase the risk of infections and death.
People with alcoholic hepatitis are susceptible to infections, especially when taking steroids. They are also vulnerable to alcohol withdrawal. Lorazepam and oxazepam are the typically recommended drugs for preventing and treating alcohol withdrawal. In terms of nutrition, it’s also important to monitor daily caloric intake. If patients are consuming less than 1200 calories per day, nutritional supplementation should be considered.
Both pentoxifylline and prednisolone are commonly recommended for severe alcoholic hepatitis, but their long-term benefits are unclear.
In some severe cases where there’s no response to steroids treatment, a liver transplant may be considered. However, this can be a controversial option due to concerns about a patient’s ability to maintain sobriety, availability of organs for transplant, and various social and ethical issues. In a 2015 survey, only 27% of liver transplant programs offered a transplant to patients with alcoholic hepatitis. These patients, if they did undergo transplantation, had similar survival rates and alcohol recidivism rates as those transplanted for alcohol-related cirrhosis.
If the patient has symptoms related to kidney failure or neurological changes, specialists such as a nephrologist or neurologist should be consulted. For symptoms suggesting an infection, it’s necessary to obtain consultation from an infectious disease specialist.
What else can Alcoholic Hepatitis (Alcohol-related Liver Damage) be?
When the doctor is determining whether a patient has alcoholic hepatitis, there are several other conditions they might consider as alternative diagnoses because they cause similar symptoms. These include:
- Nonalcoholic steatohepatitis, a condition where fat and inflammation damage the liver
- Acute or chronic viral hepatitis, diseases that attack the liver
- Drug-induced liver injury, which occurs when a medication harms the liver
- Fulminant Wilson disease, a severe form of a rare inherited disorder that causes copper to accumulate in vital organs
- Autoimmune liver disease, when the body’s immune system attacks the liver
- Alpha-1 antitrypsin deficiency, a genetic disorder that can affect the lungs and liver
- Pyogenic hepatic abscess, a pocket of pus in the liver
- Ascending cholangitis, an infection of the bile ducts
- Decompensation associated with hepatocellular carcinoma, or liver cancer
Conducting proper tests and considering these possibilities is crucial for the doctor to correctly identify the patient’s condition.
What to expect with Alcoholic Hepatitis (Alcohol-related Liver Damage)
People suffering from severe alcoholic hepatitis with an MDF score over 32 have a 30 to 50% chance of dying within 30 days from the disease. Within half a year of contracting the disease, it leads to the death of around 40% of patients. If the patient is exhibiting symptoms like jaundice and hepatic encephalopathy at the time of diagnosis, it generally points towards a worse prognosis.
On the other hand, mild cases of alcoholic hepatitis are usually benign and not threatening. The damage done by this type of hepatitis can also be completely undone by stopping alcohol consumption.
There are four main factors to consider when predicting the outcome of the disease:
1. Proven alcoholic hepatitis in tissue analysis.
2. A serum bilirubin level higher than 2.5 mg/dl.
3. A serum albumin level of less than 2.5 g/dl.
4. A prothrombin time longer than 5 seconds.
Possible Complications When Diagnosed with Alcoholic Hepatitis (Alcohol-related Liver Damage)
Alcoholic hepatitis can lead to several complications, which include:
- Bleeding from the enlarged veins in the esophagus or stomach (Variceal hemorrhage)
- Confusion, changes in mood, and sluggish movement due to liver damage (Hepatic encephalopathy)
- Blood’s inability to clot as it should (Coagulopathy)
- Low platelet count in the blood (Thrombocytopenia)
- Build-up of fluid in the abdomen (Ascites)
- Infection of the fluid in the abdomen (Spontaneous bacterial peritonitis)
- Excess iron in the body (Iron overload)
Recovery from Alcoholic Hepatitis (Alcohol-related Liver Damage)
People should aim to eat a diet that includes 100 grams of protein each day, alongside a variety of multivitamins including folate and thiamine. Not getting enough protein and energy from food is a common issue for alcoholics, leading to a higher risk of death compared to those who are not malnourished. If an individual doesn’t have a condition called encephalopathy, there’s no need to limit their protein intake.
Preventing Alcoholic Hepatitis (Alcohol-related Liver Damage)
People suffering from alcoholic hepatitis require ongoing monitoring and care. Participating in support groups, like Alcoholics Anonymous (AA), or similar alcohol abuse assistance programs, can be extremely beneficial for many individuals. Regular tests for viral hepatitis should also be scheduled, and routine checks for liver cancer are strongly recommended.
In order to protect their health, people with alcoholic hepatitis should be vaccinated against hepatitis A and hepatitis B, as well as the influenza A virus, and pneumococcus, which can lead to pneumonia. This prevention can help them to stay healthier and reduce their risk of complications associated with these diseases.
