Alcoholic Hepatitis Management
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Direct answer
A bilirubin crossing the teens in a daily drinker with tender hepatomegaly, AST typically in the 200-400 range with an AST:ALT ratio over 2 and deep hyperbilirubinaemia, defines severe alcoholic hepatitis — a distinct syndrome of hepatocellular inflammation superimposed on alcoholic liver disease, carrying 28-day mortality near a third when untreated. Severity gates therapy: a Maddrey discriminant function (4.6 × [prothrombin time − control] + bilirubin in mg/dL) of 32 or more, or a MELD above 21, earns prednisolone 40 mg daily — the answer being prednisolone, not prednisone, in liver disease — with the Lille score at day 7 deciding continuation (under 0.45 respond and complete 28 days; 0.45 or more is steroid failure, stop). Abstinence is the only curative intervention; N-acetylcysteine infusion alongside steroids shows signals of improved infection-free survival, early liver transplantation is emerging in selected steroid non-responders, and all patients need thiamine, nutritional support (35-40 kcal/kg, 1.5 g/kg protein) and alcohol relapse prevention.
What you must remember
- The laboratory fingerprint: AST 200-400 U/L with AST:ALT ratio above 2 (both under 400-500, higher values suggest other causes), bilirubin often over 15-20 mg/dL, high INR, raised GGT, macrocytosis and a low platelet count from underlying cirrhosis — "AST moderate, ratio 2:1, bilirubin massive".
- Maddrey discriminant function arithmetic: 4.6 × (patient PT − control PT) + total bilirubin (mg/dL); 32 or more defines severe disease and the steroid threshold — a calculation NEET-PG asks outright.
- Alternative severity gates: MELD above 21 (28-day mortality around 20-30 percent), Glasgow alcoholic hepatitis score of 9 or more, and the ABIC score — know that MELD is the transplant-currency alternative.
- The steroid protocol: prednisolone 40 mg orally daily for 28 days; Lille score at day 7 — 0.45 or greater means non-response and steroids are withdrawn to spare infection risk.
- Infection before immunosuppression: blood, urine and ascitic cultures plus a diagnostic paracentesis precede the first steroid dose; active infection, gastrointestinal bleeding and hepatorenal syndrome exclude steroid use until treated.
- Nutrition is therapy: 35-40 kcal/kg/day and 1.2-1.5 g/kg/day protein enterally — the malnourished alcoholic who is fed improves; thiamine 100 mg daily (before glucose), folate and multivitamins mandatory.
- What does not work: pentoxifylline failed in the STOPAH trial for mortality benefit; prednisolone improves 28-day but not six-month survival unless abstinence follows.
- The abstinence dividend: sustained abstinence is the strongest predictor of long-term survival in alcoholic hepatitis and cirrhosis — relapse prevention (baclofen in cirrhosis where indicated, psychosocial programmes) is a medical, not merely behavioural, prescription.
Steroids or not: a ward round decision
A 44-year-old man with 20 years of daily drinking presents with jaundice of three weeks, tender hepatomegaly, bilirubin 22 mg/dL, AST 310 with ALT 118, INR 2.0 (PT 24 seconds against a control of 13), creatinine 1.1. The Maddrey function computes as 4.6 × (24 − 13) + 22 = 72.6 — severe disease, well above 32. Before any prescription: cultures are drawn, ascitic fluid shows no spontaneous bacterial peritonitis, no gastrointestinal bleeding, no hepatorenal syndrome. Prednisolone 40 mg daily begins, with N-acetylcysteine infusion running alongside and enteral nutrition targets set at 2,000-plus calories with 90-100 g protein; thiamine precedes every dextrose-containing fluid. Day 7 recalculates the Lille score from the falling bilirubin — 0.32, a responder — so the 28-day course completes, with transplant counselling and an addiction-medicine plan because steroids only buy a window.
The mirror case: identical presentation, day-7 Lille of 0.61 — steroid failure. Steroids stop; management pivots to supportive care, infection vigilance and, where a programme exists, evaluation for early liver transplantation in the carefully selected abstinent-committed patient, a strategy supported by recent trials in steroid non-responders without prior decompensation.
Scoring traps
The arithmetic of Maddrey trips candidates who forget the control PT subtraction or plug in seconds versus seconds inconsistently — the exam gives the numbers expecting 4.6 × difference + bilirubin; practise it until automatic. The second trap is prednisone versus prednisolone: the liver must convert prednisone to its active form, so prednisolone is the answer written in guidelines. The third is the Lille cutoff direction — below 0.45 continue, 0.45 or above stop — reversed in many mistaken answers. Indian stems also embed the infection exclusion: a fever line or ascitic neutrophil count of 300/mm³ must move the first step to cefotaxime and albumin, deferring steroids — giving prednisolone into untreated infection is the classic wrong answer the examiner dangles.
Frequently asked questions
How is the Maddrey discriminant function calculated and interpreted?
As 4.6 × (prothrombin time − control prothrombin time) + bilirubin in mg/dL; a value of 32 or more defines severe alcoholic hepatitis and qualifies the patient for corticosteroid therapy.
What is the steroid regimen for severe alcoholic hepatitis?
Prednisolone 40 mg daily for 28 days, with the Lille score at day 7 deciding the course — below 0.45, continue to completion; 0.45 or greater indicates non-response and steroids are stopped.
Which features suggest alcoholic hepatitis rather than viral or other hepatitis?
A history of heavy alcohol use, AST in the 200-400 range with an AST:ALT ratio above 2, marked hyperbilirubinaemia with tender hepatomegaly, macrocytosis and a high GGT.
Why must infection be excluded before starting steroids?
Because corticosteroids worsen uncontrolled infection — the leading competitor for early mortality — so cultures and diagnostic paracentesis precede the first dose, and active infection or gastrointestinal bleeding contraindicates steroids.
What nutritional support does alcoholic hepatitis need?
Aggressive enteral nutrition — 35-40 kcal/kg/day and 1.2-1.5 g/kg/day protein — with parenteral thiamine before any glucose infusion, folate and multivitamin supplementation; malnutrition independently predicts mortality.