Alcoholic hepatitis natural history, complications and prognosis

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Shadan Mehraban, M.D.[2]

Alcoholic liver disease may progress to fatty liver, hepaticsteatosis, Alcoholic hepatitis, alcoholic steatonecrosis,fibrosis, cirrhosis and hepatocellular carcinoma. Complications of Alcoholic hepatitis include [[variceal hemorrhage,hepatic encephalopathy,ascites,Coagulopathy, thrombocytopenia,spontaneous bacterial peritonitis, and iron overload. Different scoring systems were presented to predict the prognosis and mortality among patients with Alcoholic hepatitis. The most recent and accurate one is called Asymmetric dimethylarginine (ADMA) score.

• Alcoholic liver disease may progress to one of the following stages:^{[1] [2]}
  • Fatty liver or hepaticsteatosis
  • Steatohepatitis defined as Alcoholic Hepatitis or alcoholic steatonecrosis
  • Fibrosis
  • Cirrhosis and hepatocellular carcinoma (HCC)
• The liver biopsy of around 20-40% of the individuals with steatosis is suggestive of steatohepatitis
• After development of steatohepatitis, the hepatic change is irreversible, even after the abstinence

• Complications of Alcoholic Hepatitis include: ^[3]
  • Variceal hemorrhage
  • Hepatic encephalopathy
  • Ascites
  • Coagulopathy and thrombocytopenia
  • Spontaneous bacterial peritonitis
  • Iron overload

• Compared to steatosis, development of Alcoholic Hepatitis is associated with nine -times higher risk of developing cirrhosis as well as 40 % chance of 180- days mortality.^[4]
• Continuing alcohol consumption can lead to development of cirrhosis in 70 % subjects with Alcoholic Hepatitis^[5]
• Alcoholic Hepatitis is considered to be fatal as 1-year mortality rate among subjects is 25%. ^[6]
• The progression of precirrhotic disease to cirrhosis are reported as the following rates:^[7]
  • 1% (0-8%) for patients with normal histology
  • 3% (2-4%) for hepatic steatosis
  • 10% (6-17%) for steatohepatitis
  • 8% (3-19%) for fibrosis
• Maddrey et al. described Discriminant Function (DF), is a predictor of severity of Alcoholic Hepatitis:^[8]
  • DF score is calculated by the following formula:
    • DF = 4.6 x (PT – control PT) + Total Bilirubin
  • DF score > 32 is suggestive of severe disease and 30-day mortality rate is 50% without steroids treatment
  • DF score is not an accurate system for estimating the mortality and prognosis among those who received treatment
• Model for End-Stage Liver Disease (MELD) predicts mortality risk in patients with end-stage liver disease^[9]
  • MELD score ≥21 within 24 hours of presentation predicts of 90-day mortality
  • MELD and DF scores are similar in predicting both 30-day and 90-day mortality
• Glasgow Alcoholic Hepatitis Score (GAHS) is another scoring system which calculated the risk based on age, serum bilirubin, blood urea nitrogen, PT, and peripheral WBCcount ^[10]
  • GASH score ≥ 9 is a predictor of mortality
  • GASH is more accurate than DF in predicting both 28- and 84-day mortality
  • GASH scoring system is similar to MELD in predicting the 28-day mortality
• Asymmetric dimethylarginine (ADMA) score is the most recent predictor of severe Alcoholic Hepatitis ^[11]
  • ADMA score is a better predictor of outcomes of Alcoholic Hepatitis than other scoring systems

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