Alcoholic hepatitis: Clinical manifestations and diagnosis
- Scott L Friedman, MD
Scott L Friedman, MD
- Fishberg Professor of Medicine
- Icahn School of Medicine at Mount Sinai
- Section Editor
- Bruce A Runyon, MD
Bruce A Runyon, MD
- Section Editor — Cirrhosis and Its Complications
- Clinical Professor of Medicine
- University of New Mexico, Division of Gastroenterology and Hepatology
- Special Hepatology Consultant to the Indian Health Service
- Northern Navajo Medical Center, Shiprock, New Mexico
Excessive alcohol consumption is associated with a range of hepatic manifestations, including alcoholic fatty liver disease (with or without steatohepatitis), alcoholic hepatitis, and cirrhosis. The burden of alcoholic liver disease continues to grow [1,2]. While asymptomatic steatohepatitis due to alcohol could be referred to as "alcoholic hepatitis," the term is typically used to describe the acute onset of symptomatic hepatitis. The amount of alcohol intake that puts an individual at risk for alcoholic hepatitis is not known, but the majority of patients have a history of heavy alcohol use (more than 100 g/day) for two or more decades (figure 1) [3-5]. Clinicians should not overlook the long-term need to encourage treatment for alcohol use disorder once the acute episode of alcoholic hepatitis has resolved . (See "Risky drinking and alcohol use disorder: Epidemiology, pathogenesis, clinical manifestations, course, assessment, and diagnosis".)
This topic will review the clinical manifestations and diagnosis of alcoholic hepatitis. The management of alcoholic hepatitis, the pathogenesis of alcoholic liver disease, and the approach to patients with alcoholic fatty liver disease or alcoholic cirrhosis are discussed separately. (See "Alcoholic hepatitis: Natural history and management" and "Pathogenesis of alcoholic liver disease" and "Clinical manifestations and diagnosis of alcoholic fatty liver disease and alcoholic cirrhosis" and "Prognosis and management of alcoholic fatty liver disease and alcoholic cirrhosis".)
Guidelines for the management of patients with alcoholic liver disease were issued in 2010 by the American Association for the Study of Liver Diseases . The discussion that follows is generally consistent with those guidelines.
Patients with alcoholic hepatitis are often between 40 and 50 years of age, with most patients presenting before the age of 60 years . Patients with alcoholic hepatitis typically have a history of daily heavy alcohol use (>100 g/day) for more than 20 years (figure 1) and in some cases, patients will have recently increased their alcohol intake in response to stressful life events . Patients often stop drinking as they become ill, so it is common for patients to have ceased alcohol intake several weeks prior to presentation [3,4,10,11]. Drinking patterns may vary, however, and heavy drinking can be intermittent (ie, weekends only) or surreptitious, such that family members, friends, or coworkers may not recognize a pattern of problem drinking. In addition, alcoholic hepatitis can develop in patients with much shorter histories of heavy alcohol use .
Obtaining an accurate history of alcohol use from a patient with suspected alcoholic hepatitis may be difficult. Questioning the patient's family in private, after receiving permission from the patient to discuss his or her care with family members, may help elicit important information about the patient's alcohol use. It is also absolutely essential that health care providers take a careful alcohol history, supplemented by use of either the CAGE or AUDIT questionnaires to establish the likelihood of problem alcohol drinking or abuse (table 1 and table 2). (See "Screening for unhealthy use of alcohol and other drugs in primary care", section on 'Unhealthy alcohol use'.)
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- CLINICAL MANIFESTATIONS
- Signs and symptoms
- Physical examination
- Laboratory tests
- - Liver test abnormalities
- - Coagulation abnormalities
- - Hematologic abnormalities
- - Other laboratory test abnormalities
- Imaging tests
- Diagnostic approach
- Pathologic criteria for alcoholic hepatitis
- Assessing disease severity
- DIFFERENTIAL DIAGNOSIS
- Acute hepatitis
- Chronic liver disease
- SUMMARY AND RECOMMENDATIONS