Alcoholic Hepatitis

What alcoholic hepatitis is

The liver breaks down alcohol, producing toxic byproducts such as acetaldehyde. Over time, heavy drinking causes fat to build up in liver cells (fatty liver). In some people, the liver then becomes acutely inflamed: liver cells swell, die and are infiltrated by white blood cells. This is alcoholic hepatitis. It sits within the spectrum of alcoholic liver disease, alongside fatty liver and cirrhosis. Many people with alcoholic hepatitis already have cirrhosis.

Despite the name "hepatitis", it is not caused by a virus and is not contagious.

Symptoms

Symptoms usually develop over a few weeks, often after a period of increased drinking:

• Jaundice: yellow eyes and skin, dark urine
• Tender, enlarged liver under the right ribs
• Fever (even without infection)
• Loss of appetite, nausea, weight loss and muscle wasting
• Fatigue and weakness
• Swollen belly (ascites) and swollen legs
• Easy bruising and bleeding
• Confusion, drowsiness or personality changes (hepatic encephalopathy) in severe cases

Mild cases may only show up as abnormal blood tests.

Risk factors

• Amount and duration of drinking. Most patients have drunk heavily for years, though only a minority of heavy drinkers develop it
• Binge drinking on top of daily heavy drinking
• Women develop liver damage at lower alcohol amounts than men
• Obesity and metabolic syndrome
• Genetic factors (such as variants in the PNPLA3 gene)
• Malnutrition
• Coexisting hepatitis B or C

Diagnosis

Diagnosis is usually clinical, based on:

1. History: heavy alcohol use for more than 6 months, with less than about 60 days since the last heavy drinking, and jaundice starting within the past 8 weeks.
2. Blood tests: raised bilirubin (above 3 mg/dL), AST raised more than ALT, typically in a ratio of about 2 to 1, with AST usually below 400 U/L. High white cell count, low albumin and prolonged INR (clotting time).
3. Imaging: ultrasound to look for cirrhosis, ascites and to exclude blocked bile ducts or liver tumors.
4. Tests to exclude other causes: viral hepatitis, autoimmune hepatitis, drug-induced liver injury (including acetaminophen).
5. Liver biopsy: only when the diagnosis is uncertain.

Severity scores

Treatment

Stopping alcohol

Complete, lasting abstinence is the single most important factor in survival, both in the short and long term. Alcohol withdrawal is managed in hospital when needed because it can be dangerous. Long-term treatment for alcohol use disorder, including counseling, mutual support groups and medicines such as acamprosate or baclofen (chosen for their liver safety), greatly improves outcomes.

Nutrition

Most patients are malnourished. Guidelines recommend high-calorie, high-protein nutrition (around 35 to 40 kcal and 1.2 to 1.5 g protein per kg of body weight per day), with late-evening snacks, tube feeding if needed, and thiamine and other vitamins.

Medicines for severe disease

• Corticosteroids (prednisolone) for 28 days improve short-term survival in severe cases (MDF 32 or more, or MELD above about 20) without active infection, bleeding or kidney failure. Response is checked at day 4 to 7 with the Lille score.
• N-acetylcysteine combined with steroids may add benefit in some studies.
• Pentoxifylline is no longer recommended as it does not improve survival.

Managing complications

• Screening for and treating infections, which are common and a major cause of death
• Treating kidney injury (hepatorenal syndrome), encephalopathy and ascites
• Endoscopy for bleeding varices

Liver transplant

Early liver transplant is increasingly offered at selected centers to carefully chosen patients with severe alcoholic hepatitis who do not respond to medical treatment and have strong social support and commitment to abstinence.

Outlook

Mild alcoholic hepatitis often improves within weeks to months after stopping drinking. Severe alcoholic hepatitis is life-threatening: roughly 20 to 30 percent of people die within 1 month and up to 30 to 50 percent within 6 months, depending on severity. Those who survive and stay abstinent can see substantial liver recovery, although existing cirrhosis may remain. Returning to drinking carries a high risk of recurrence and death.

Prevention

• Keep within recommended limits: no more than 1 drink a day for women and 2 for men in US guidance, or avoid alcohol altogether.
• Get help early for problem drinking. Call the SAMHSA National Helpline at 1-800-662-4357 (US) for free, confidential treatment referral.
• Get vaccinated against hepatitis A and B if you have liver disease.

Frequently asked questions

What are the symptoms of alcoholic hepatitis?

Common symptoms are yellowing of the skin and eyes, a tender, swollen liver, fever, fatigue, poor appetite, nausea and a swollen belly. Severe cases cause confusion, bleeding and kidney problems. Symptoms usually develop over weeks in someone who has been drinking heavily.

Can you recover from alcoholic hepatitis?

Yes, many people recover, especially from mild to moderate disease, if they stop drinking completely. The liver can regenerate substantially over months. Severe alcoholic hepatitis has a high death rate in the first months, and any existing cirrhosis is usually permanent.

What is the survival rate for alcoholic hepatitis?

It depends on severity. Mild cases have good survival. In severe alcoholic hepatitis, about 20 to 30 percent of people die within a month and up to half within 6 months. Long-term abstinence is the strongest predictor of survival.

How is alcoholic hepatitis treated?

Treatment centers on stopping alcohol completely, managing withdrawal, providing intensive nutrition, and treating infections and complications. Severe cases may receive steroids for 28 days. A small number of carefully selected patients who do not respond may be considered for liver transplant.

Is alcoholic hepatitis the same as cirrhosis?

No. Alcoholic hepatitis is acute inflammation of the liver, which can partly reverse with abstinence. Cirrhosis is permanent scarring. They often coexist, and repeated bouts of alcoholic hepatitis speed the progression to cirrhosis.