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Alcoholic hepatitis: Natural history and management

Author
Scott L Friedman, MD
Section Editor
Bruce A Runyon, MD
Deputy Editor
Anne C Travis, MD, MSc, FACG, AGAF

INTRODUCTION

Excessive alcohol consumption is associated with a range of hepatic manifestations and takes a significant toll on human health throughout the world [1,2]. In the United States, the burden of alcoholic hepatitis is increasing [3]. Hepatic manifestations include alcoholic fatty liver disease (with or without steatohepatitis), alcoholic hepatitis, and cirrhosis. 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) [4,5].

This topic will review the prognosis and management of patients with alcoholic hepatitis. The pathogenesis of alcoholic liver disease, the clinical manifestations and diagnosis of alcoholic hepatitis, and the approach to patients with alcoholic fatty liver disease or alcoholic cirrhosis are discussed separately. (See "Pathogenesis of alcoholic liver disease" and "Alcoholic hepatitis: Clinical manifestations and diagnosis" 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 [6]. The discussion that follows is generally consistent with those guidelines.

NATURAL HISTORY

Mortality rates among patients who do not receive pharmacologic therapy (eg, prednisolone) for alcoholic hepatitis are variable. In patients with severe alcoholic hepatitis (typically defined by a Maddrey discriminant function ≥32 (calculator 1)), short-term mortality rates are high (approximately 25 to 45 percent at one month) [7-10], whereas patients with mild to moderate alcoholic hepatitis have low short-term mortality rates (<10 percent at one to three months) [11,12]. (See 'Determining disease severity' below.)

In a pooled analysis of 661 patients with alcoholic hepatitis who had received placebo in randomized trials, the overall mortality rate after a median of 160 days was 34 percent [7]. The primary causes of death were hepatic failure (55 percent), gastrointestinal bleeding (21 percent), and sepsis (7 percent). When mortality rates were examined based on study inclusion criteria, one-month mortality rates were higher in trials that included only patients with severe alcoholic hepatitis compared with trials that included patients with both moderate and severe alcoholic hepatitis or trials that did not specify severity (23 versus 21 and 11 percent, respectively).

                      

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Literature review current through: Nov 2016. | This topic last updated: Fri Jun 03 00:00:00 GMT+00:00 2016.
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