# Alcoholic Hepatitis Management

> Alcoholic hepatitis management for NEET-PG Medicine: Maddrey score 32, prednisolone 40 mg, Lille response at day 7 and abstinence.

- Canonical URL: https://prepelephant.com/topics/neet-pg/medicine/alcoholic-hepatitis-management
- Exam / course: NEET-PG · Subject: Medicine
- Publisher: PrepElephant (https://prepelephant.com) — Prepared and reviewed by the PrepElephant Academic Review Team
- First published: 2026-10-02
- Last updated: 2026-10-02
- How to cite: "Alcoholic Hepatitis Management", PrepElephant, https://prepelephant.com/topics/neet-pg/medicine/alcoholic-hepatitis-management

## 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.