Alcoholic Hepatitis

Alcohol-associated hepatitis, Alcohol-induced hepatitis

Alcoholic hepatitis is a serious liver condition caused by heavy alcohol use that leads to inflammation and damage of liver cells. While mild cases may improve with proper care, severe cases can be life-threatening, with high mortality rates even with treatment.

Table of contents

• What is alcoholic hepatitis?
• What causes this condition?
• Who can get alcoholic hepatitis?
• Signs and symptoms
• How is it diagnosed?
• Treatment approaches
• Possible complications
• Outlook and prognosis

• Liver

What is alcoholic hepatitis?

Alcoholic hepatitis is a type of liver damage and swelling caused by drinking alcohol. The liver is a large organ located mainly in the upper right portion of the abdomen, beneath the diaphragm and above the stomach. It helps filter toxins from the blood, aids digestion, regulates blood sugar and cholesterol levels, and helps fight infection and disease.^[1]

Hepatitis means inflammation of the liver that leads to liver cell damage and cell death. This swelling, called inflammation, damages liver cells over time. The term “alcohol-associated hepatitis” is increasingly used by experts to reduce stigma and emphasize the medical nature of the disease.^[1]

Alcoholic hepatitis is a serious form of alcohol-associated liver disease. This broader category includes several types of liver conditions caused by alcohol, from fat deposits in the liver to severe liver scarring called cirrhosis. Alcoholic hepatitis is characterized by rapid onset of jaundice, malaise, tender enlargement of the liver, and subtle features of systemic inflammatory response.^[3]

Not everyone who drinks heavily will develop liver disease, but it is common. Studies show that up to 1 in 3 people with alcohol use disorder will develop some kind of alcohol-related liver disease.^[1]

What causes this condition?

Alcoholic hepatitis is caused by drinking too much alcohol. The liver breaks down alcohol when it passes through for processing. However, alcohol acts as a toxin in the body. It offers no nutritional value and instead breaks down into poisonous chemicals.^[2]

Over time, if you drink more alcohol than the liver can process, it can become severely damaged. Chronic, heavy alcohol use, or alcohol use disorder, can overload your liver with fat and toxins to process. When your liver can no longer keep up, these toxins and fat build up and begin to injure the liver. The injury produces an inflammatory response, which is your body’s way of attempting to heal and ward off further injury.^[2]

Like a fever, inflammation is supposed to be a temporary intervention. But when the assault is constant, the inflammation becomes constant. In the liver, this means swelling with fluid. If the swelling is severe and persistent, over time it will damage the tissues, causing cell death.^[2]

The National Institute on Alcohol Abuse and Alcoholism defines alcoholic hepatitis to include the onset of jaundice within 60 days of heavy alcohol consumption (more than 50 grams per day) for a minimum of 6 months, serum bilirubin more than 3 milligrams per deciliter, elevated liver enzyme levels, and no other cause of acute hepatitis.^[3]

Who can get alcoholic hepatitis?

You’re more at risk if you use alcohol heavily over many years. Alcoholic hepatitis most often occurs in people who have been drinking heavily for many years. It also can affect people who binge drink.^[1]

Heavy drinking means different things for men and women. For males, it’s about four standard drinks a day or more than 14 drinks per week. For females, it’s about three drinks per day or more than 7 drinks per week.^[2]

However, not everyone who gets alcoholic hepatitis fits this profile. Some people are more sensitive to alcohol, and their livers react to even moderate use. Others may be able to drink more without inducing hepatitis. Genetic differences may partially explain this. You may be more at risk if you have a family history of alcohol use disorder or liver disease. Sex differences also play a part. In general, men can tolerate more alcohol.^[2]

Risk factors for the development of the disease include prolonged and heavy alcohol use, younger age, female sex, genetic susceptibility, higher body mass index, and comorbid liver disease. Obese people and tobacco smokers are at higher risk of alcoholic hepatitis, or a more complicated course.^[5][6]

Everyone is different, and medically there is no safe amount of alcohol that can be defined. Some people develop alcohol-associated hepatitis and cirrhosis from seemingly insignificant quantities of alcohol.^[2]

Signs and symptoms

Alcoholic hepatitis does not usually cause any symptoms until the liver has been severely damaged. If you only have mild or early hepatitis, you might not have any symptoms.^[2][4]

The most common symptom of alcoholic hepatitis is the skin and whites of the eyes turning yellow. This condition is called jaundice. Jaundice happens when a substance called bilirubin builds up in the body. Bilirubin is a yellow-colored waste product.^[1]

As the disease progresses, you may begin to notice:^[2][5]

• Tenderness or soreness in your upper right abdomen, where your liver is
• Visibly swollen or enlarged liver
• A distended abdomen, or swelling with fluid in your abdomen
• Loss of appetite and weight loss
• Upset stomach (nausea)
• Vomiting blood or material that looks like coffee grounds
• Tiredness and weakness
• Light-colored stools that float
• Fever

When severe hepatitis has begun to interfere with your liver’s functioning, you may begin to notice signs of these complications, such as:^[2]

• Fast heart rate
• Easy bleeding and bruising
• Confusion, decreased levels of consciousness, or drowsiness (a condition called hepatic encephalopathy, which is brain dysfunction due to liver failure)
• Fatigue and malaise

Alcoholic hepatitis usually develops over time with continued drinking. But severe alcoholic hepatitis can develop suddenly. It can quickly lead to liver failure and death.^[5]

Many of these symptoms may be caused by other health problems. Always see a healthcare provider for a diagnosis.^[5]

How is it diagnosed?

Diagnosis of alcoholic hepatitis is primarily clinical, based on a consensus definition from the National Institute on Alcohol Abuse and Alcoholism. The diagnosis must include acute-onset jaundice, specific laboratory abnormalities, and characteristic history of alcohol use (long-term consumption of roughly three standard drinks daily for women and four standard drinks daily for men).^[6]

To get the right diagnosis, it’s important to be honest about alcohol use, now and in the past. Sometimes a healthcare professional might ask to talk to family members about a loved one’s drinking. Your healthcare provider will take a complete health history and do a physical exam.^[9]

You may need several tests, including:^[5]

Blood tests are essential for diagnosis. These include liver function studies, blood cell counts, bleeding times, electrolyte tests, and tests for other chemicals in the body. Liver function tests (LFTs) are blood tests that help your healthcare team understand how well your liver is working. In alcoholic hepatitis, typical results may include:^[9]

• Aspartate aminotransferase (AST) and alanine aminotransferase (ALT): A common finding is an AST to ALT ratio greater than 2 to 1, which suggests alcohol-related liver injury
• Total bilirubin: High bilirubin levels can cause yellowing of the skin and eyes
• International normalized ratio (INR) or prolonged prothrombin time (PT): High levels mean the liver isn’t making enough clotting proteins, which increases bleeding risk
• Albumin: Low albumin levels show poor liver function and possible malnutrition

Imaging tests may also be performed:^[5]

• Ultrasound of the abdomen: This imaging uses sound waves to show internal structures without using radiation
• CT scan: This imaging test uses X-rays and a computer to make detailed images of any part of the body, including the liver
• MRI: Magnetic resonance imaging uses a magnetic field, radio frequency pulses, and a computer to make detailed pictures of internal body structures

Liver biopsy is a test where a small tissue sample is taken from the liver with a needle or during surgery. These samples are checked under a microscope to find out the type of liver disease. Liver biopsy is necessary only if the diagnosis is unclear and accurate diagnosis would impact management.^[5][6]

Initial workup should include chest radiography and cultures of peritoneal fluid, blood, and urine. Close monitoring for inflammation and organ failure is crucial throughout hospitalization. Laboratory-based prognostic scores, including Maddrey Discriminant Function and the Model for End-Stage Liver Disease, help determine disease severity and treatment options.^[6]

Treatment approaches

The goal of treatment is to prevent permanent damage to the liver and to begin healing so that the liver can function normally. Stopping alcohol use is the most important step in treating alcoholic hepatitis along with focusing on nutrition. Continuing to drink alcohol after being diagnosed with alcoholic hepatitis greatly increases the risk of liver failure and death.^[1]

Stopping drinking alcohol: You’ll need to stop drinking alcohol. To do this, you may need to be in an alcohol treatment program. If you’re abstaining from alcohol, you may suffer withdrawal symptoms. These will be at their worst for the first 48 hours, but should start to improve as your body adjusts to being without alcohol. This usually takes 3 to 7 days from the time of your last drink.^[4][19]

In some cases, you may be advised to reduce your alcohol intake in a gradual and planned way to help avoid withdrawal problems. You may also be offered a medicine called a benzodiazepine and psychological therapy, such as cognitive behavioral therapy (CBT), to help you through the withdrawal process.^[19]

Pharmacologic treatment of alcohol use disorder can aid patients in maintaining abstinence from alcohol. A medicine called naltrexone is very effective at decreasing cravings and drinking. It comes as a daily pill or as a once a month injection called vivatrol.^[6]

Nutritional support: Malnutrition is common in people with alcoholic hepatitis, so it’s important to eat a balanced diet to make sure you get all the nutrients you need. Sometimes you may also need to change your diet. Avoiding salty foods and not adding salt to foods you eat can reduce your risk of developing swelling in your legs, feet and tummy caused by a build-up of fluid.^[4][19]

The damage to your liver can also mean it’s unable to store glycogen, a carbohydrate that provides short-term energy. When this happens, the body uses its own muscle tissue to provide energy between meals, which leads to muscle wasting and weakness. This means you may need extra energy and protein in your diet. Healthy snacking between meals can top up your calories and protein. It may also be helpful to eat 3 or 4 small meals a day, rather than 1 or 2 large meals.^[19]

Daily energy intake of 35 to 40 kilocalories per kilogram of body weight and a daily protein intake of 1.2 to 1.5 grams per kilogram of body weight should be provided. In the most serious cases of malnutrition, nutrients may need to be provided through a feeding tube inserted through the nose and into the stomach.^[6][19]

Medication for severe cases: Corticosteroids are recommended for severe alcoholic hepatitis without active infection. Treatment for moderate disease primarily consists of supportive care, including alcohol cessation and nutritional support. Corticosteroids may be used to reduce inflammation of the liver in some people with severe alcoholic hepatitis.^[6][19]

Responsiveness to corticosteroid therapy should be evaluated using the Lille score on day 7 of treatment. The response rate to glucocorticosteroids is about 60 percent.^[6][7]

There is no specific medical treatment for mild alcoholic hepatitis. If scarring of the liver occurs, it’s permanent. But if it’s caught early, the liver can often fix some of the damage caused by alcohol so you can live a normal life. With time and staying sober, the liver can often heal itself.^[5]

Hospital care: For people with severe alcoholic hepatitis, treatment in hospital may be necessary. Hospital physicians should involve a multidisciplinary team, including substance abuse specialists, gastroenterologists or hepatologists, nephrologists, dietitians, and intensivists, as appropriate.^[6]

Liver transplantation: A liver transplant may be required in severe cases where the liver has stopped functioning and does not improve when you stop drinking alcohol. You’ll only be considered for a liver transplant if you have developed complications of cirrhosis despite having stopped drinking. All liver transplant units require people with alcoholic hepatitis to not drink alcohol while awaiting the transplant, and for the rest of their life.^[4]

Possible complications

Alcoholic hepatitis increases your risk for liver cancer. This is especially true if cirrhosis is present. If you continue to drink alcohol, the liver will continue to be damaged. Over time, cirrhosis will occur. Cirrhosis can cause the pressure in the liver blood vessels to increase. This can lead to life-threatening bleeding from the esophagus or stomach.^[5]

Life-threatening complications of alcohol-related liver disease include:^[4]

• Internal (variceal) bleeding
• Build-up of toxins in the brain (encephalopathy)
• Fluid accumulation in the abdomen (ascites) with associated kidney failure
• Liver cancer
• Increased vulnerability to infection

High rates of concomitant infections, systemic inflammation, and multiorgan failure lead to significant morbidity and mortality.^[6]

Outlook and prognosis

In most patients with alcoholic hepatitis, the illness is mild. The short-term prognosis is good, and no specific treatment is required. Hospitalization is not always necessary.^[6]

In contrast, patients with severe acute alcoholic hepatitis are at a high risk for early death, at a rate of 50 percent or greater within 30 days. Overall and in-hospital mortality are high for severe alcoholic hepatitis, with a 28-day mortality rate of 16 to 30 percent and a one-year mortality rate of 56 percent.^[6]

The presence of underlying cirrhosis and continued alcohol use negatively impact long-term prognosis. Only prolonged alcohol abstinence is of demonstrated benefit in improving liver function, preventing progression to cirrhosis, and reducing mortality.^[6]

If you have fatty liver disease, the damage may be reversed if you abstain from alcohol for a period of time (this could be months or years). After this point, it’s usually safe to start drinking again if you stick to recommended guidelines on alcohol units. However, it’s important to check with your doctor first.^[4]

If you have a more serious form of alcohol-related liver disease (alcoholic hepatitis or cirrhosis), lifelong abstinence is recommended. This is because stopping drinking is the only way to prevent your liver damage getting worse and potentially stop you dying of liver disease.^[4]

Death rates linked to alcohol-related liver disease have risen considerably over the last few decades. Alcohol misuse is now one of the most common causes of death in the United Kingdom, along with smoking and high blood pressure.^[4]