Info
🌱 來自: Huppert’s Notes
Alcohol-Induced Liver Disease🚧 施工中
Alcohol-Induced Liver Disease
Alcoholic hepatitis
• Clinical features: Jaundice, anorexia, fever, tender hepatomegaly
• Diagnosis: Moderate elevation in transaminases (AST:ALT ratio ≥2) in a patient with a history of prolonged and heavy alcohol use (often >100 g/day for >20 yr); requires exclusion of other causes of liver disease
• Management:
- Evaluate for other causes of acute hepatitis (e.g., HBsAg, anti-HBs, anti-HBc, Hep A IgM, acetaminophen level, RUQ ultrasound with Doppler)
- Rule out mimics, such as sepsis due to intraabdominal source or SBP (should obtain blood culture; UA, urine culture; paracentesis for culture, cell count/differential, total protein, albumin)
- Calculate MELD-Na and Maddrey’s discriminant function (MDF)
• MDF = 4.6 * (patient’s PT in seconds – control PT in seconds) + patient serum total bilirubin
• If steroids are indicated (MDF >32; indicates severe alcoholic hepatitis and 1-month mortality 35–45%), plan for steroid administration in consultation with hepatology; typical dose is prednisolone 40 mg/day for 28 days
• Calculate the Lille score at day 7. If >0.45, suggests nonresponsiveness to steroids and steroids can be stopped
• Pentoxifylline is an alternative to steroids if there are contraindications to steroid use, although this is controversial (STOPAH Trial, New Eng J Med 2015)
- If AKI is present, consider gentle fluid resucitation
- Consider peptic ulcer prophylaxis, particularly if steroids will be used
- Nutritional supplementation with thiamine, folate, and a multivitamin. Adequate nutrition is the most important intervention for alcoholic hepatitis survival and has the best data. It is not just about micronutrient deficiencies but also about ensuring adequate macronutrients. Protein intake in particular should be encouraged. Often these patients don’t feel well enough to eat and may not eat enough, so enteral feeding can be considered.
Alcoholic cirrhosis
• Epidemiology: Cirrhosis develops in 10–25% of patients with chronic heavy alcohol use
• Treatment: Alcohol cessation, liver transplantation if eligible (typically requires >6 months of abstinence from alcohol to be considered)