Alcohol-associated hepatitis: workup and management
Alcohol-associated hepatitis: rapid-onset jaundice (bilirubin >3 mg/dL) with AST/ALT elevated but usually <400 U/L and AST:ALT >1.5 after heavy alcohol use within the past 60 days. Assess severity (MELD), screen for infection, treat severe disease (MELD >20) with prednisolone plus IV N-acetylcysteine, and address alcohol use disorder.
Working diagnosis
Adult · US guidelines
Draft · awaiting physician review
01Orient
What's new in the evidence
- ACG 2024 alcohol-associated liver disease guideline: prednisolone 40 mg/day for 28 days for MELD >20 (benefit concentrated at MELD 21–39)
- IV N-acetylcysteine with corticosteroids is newly recommended; pentoxifylline is no longer recommended
- Stop steroids in non-responders by Lille score at day 4 or 7; consider early liver transplant evaluation in highly selected patients
- No routine prophylactic antibiotics; screen for infection before and during steroids
Differential diagnoses
- Alcohol-associated hepatitis
- Decompensated alcohol-associated cirrhosis without hepatitis
- Drug-induced liver injury (acetaminophen with alcohol) (can't miss)
- Biliary obstruction, ischemic hepatitis
- Viral or autoimmune hepatitis
- Infection (SBP, pneumonia) precipitating decompensation (can't miss)
02Assess
Risk scores and decision tools
- MELD (>20 = severe; steroid benefit at 21–39)
- Maddrey discriminant function (≥32 = severe)
- Lille score at day 4 or 7 (>0.45 = non-response, stop steroids)
- GAHS or ABIC for prognosis
Key history questions
- Quantity and duration of drinking; last drink
- Onset of jaundice, fever, abdominal pain, confusion
- Acetaminophen and other drug use
- Prior liver disease, infections, GI bleeding
- Social support and willingness to engage with alcohol treatment
Examination findings
- Jaundice, tender hepatomegaly, fever
- Ascites, encephalopathy (asterixis)
- Signs of infection
- Alcohol withdrawal signs
03Investigate
Initial investigations
- CMP (bilirubin, AST, ALT, albumin), INR, CBC, creatinine
- Infection screen: blood and urine cultures, chest X-ray, diagnostic paracentesis if ascites
- Acetaminophen level, viral hepatitis serologies
- Abdominal ultrasound with Doppler
Advanced investigations
- Liver biopsy (transjugular) only if the diagnosis is uncertain
- Autoimmune markers if atypical features
04Treat
Immediate management
- Treat alcohol withdrawal (lorazepam preferred in liver disease, with caution)
- Thiamine before glucose
- Treat infection before starting steroids; steroids can start once infection is controlled
First-line treatment
- MELD >20 without contraindication: prednisolone 40 mg daily for 28 days
- IV N-acetylcysteine with steroids (e.g., 150 mg/kg over 30 min, 50 mg/kg over 4 h, then 100 mg/kg/day for days 2–5)
- Nutrition 35–40 kcal/kg/day and 1.2–1.5 g/kg/day protein; enteral feeding if intake is poor
- Lille score on day 4 or 7; stop steroids if >0.45
Second-line treatment
- Early liver transplant evaluation for highly selected non-responders
- Alcohol use disorder therapy: acamprosate or baclofen; avoid naltrexone and disulfiram in severe liver disease
Specialist referrals
- Hepatology
- Addiction medicine
- Transplant center for selected non-responders
- Nutrition
05Disposition
Admission criteria
- MELD >20 or Maddrey ≥32
- Encephalopathy, infection, AKI or GI bleeding
- Severe withdrawal
Safe discharge criteria
- Improving bilirubin, eating, no infection
- Steroid plan with Lille check, abstinence plan and follow-up within 1–2 weeks
Follow-up timing
- Hepatology within 1–2 weeks; labs weekly during steroids
Patient instructions
- Complete abstinence is the main determinant of survival
- Return for fever, confusion, bleeding or abdominal swelling
Monitoring
- Bilirubin and creatinine
- Infection surveillance on steroids
- Glucose on steroids
Clinical pearls and pitfalls
- AST and ALT above ~400 U/L should prompt a search for another cause (e.g., acetaminophen)
- AKI and infection are the main predictors of death
- Steroids improve 28-day but not 90-day survival (STOPAH)
RefGuidelines and landmark evidence
For education only. Typical adult starting points; confirm doses against renal function, allergies, interactions and your institution's protocols. Not a substitute for clinical judgment or senior review.