Acute alcoholic hepatitis


Acute alcoholic hepatitis is inflammatory liver disease secondary to alcohol use.

  • Spectrum from hepatic steatosis to alcoholic hepatitis to cirrhosis
  • History of (usually chronic) alcohol abuse (~80 grams of ethanol daily for 5 years)
  • Ranges from subclinical cases to severe multisystem dysfunction

Clinical Features

Jaundice of the skin
Spider angioma
Ascites secondary to cirrhosis.



Cirrhosis is found in 50-60% of cases of alcoholic hepatitis[1]

Differential Diagnosis

Causes of acute hepatitis


Work Up


  • CBC
  • Chemistry including magnesium and phosphate
  • LFTs
    • Very high elevations possibly more suggestive of viral or drug-induced hepatitis
    • Elevated AST/ALT (characteristically >2:1 and < 500 IU/L)
    • GGT alone is less reliable (low sensitivity and specificity)[3]
  • Coagulation factors
    • Elevated PT/INR
  • Lipase if suspect pancreatitis
  • Consider viral hepatitis panel



  • Diagnosis is difficult and relies on a good history[4]
    • History of significant alcohol intake
    • Clinical evidence of liver disease
    • Supporting laboratory abnormalities
      • May be nondiagnostic in patients with mild disease or early cirrhosis
  • May also have electrolyte abnormalities from malnutrition or alcoholic ketoacidosis


Severe Alcoholic Hepatitis

  • Defined as Maddrey's DF score ≥32[5]
    • Confers mortality of 20-50% in 30 days
  • 1st line therapy: Prednisolone 40mg PO qDay x4wks[5]
    • Must assess response to treatment at 7 days with Lille score
      • If Lille score >0.45, considered as non-responder and prednisolone should be discontinued[5]
  • Pentoxifylline - evidence does not support its use[6]
  • Discontinue nonselective beta blockers (e.g., propranolol) to lower incidence of AKI[7]



  • Mild disease/low risk
  • Nutritional assessment and intervention
  • Discuss alcohol use and recommend strict abstinence


  • High risk defined as MDF ≥ 32, MELD ≥ 18, or presence of hepatic encephalopathy
  • Admission should be considered for the above as well as any of the following complications:
    • Evidence of active infection
    • Renal failure
    • Severe coagulopathy and/or liver failure
    • Alcohol withdrawal/delirium tremens


  • Maddrey Discriminant Function score (MDF)
  • Model for End-Stage Liver Disease score (MELD)
  • High risk: MDF ≥ 32, MELD ≥ 18, or presence of hepatic encephalopathy[8]

See Also

External Links


  1. Basra, Gurjot,et. al. "Symptoms and Signs of Acute Alcoholic Hepatitis." World J Hepatol. 2011 May 27; 3(5): 118–120.
  2. Ostapowicz G, Fontana RJ, Schiodt FV, et al. Results of a prospective study of acute liver failure at 17 tertiary care centers in the United States. Ann Intern Med. 2002 Dec 17; 137(12): 947-54.
  3. O'Shea RS, Dasarathy S, McCullough AJ (2010) Alcoholic liver disease. Hepatology 51: 307–328. doi: 10.1002/hep.23258
  4. O'Shea RS, Dasarathy S, McCullough AJ (2010) Alcoholic liver disease. Hepatology 51: 307–328. doi: 10.1002/hep.23258
  5. 5.0 5.1 5.2 Singal AK, et. al. ACG clinical guideline: alcoholic liver disease. Am J Gastro. 2018; 113: 175-194.
  6. Mathurin P, Louvet A, Duhamel A, et al. Prednisolone with vs without pentoxifylline and survival of patients with severe alcoholic hepatitis: a randomized clinical trial. JAMA. 2013;310(10):1033-41.
  7. Sersté T, Njimi H, Degré D, Deltenre P, Schreiber J, Lepida A, Trépo E, Gustot T, Moreno C. The use of beta-blockers is associated with the occurrence of acute kidney injury in severe alcoholic hepatitis. Liver Int. 2015 Aug;35(8):1974-82. doi: 10.1111/liv.12786. Epub 2015 Feb 4. PMID: 25611961.
  8. O'Shea RS, Dasarathy S, McCullough AJ (2010) Alcoholic liver disease. Hepatology 51: 307–328. doi: 10.1002/hep.23258