Alcoholic Hepatitis

What is Alcoholic Hepatitis?

It is an inflammatory condition or hepatitis of the liver that is caused by an excessive consumption of alcohol. The condition is frequently found in close association with hepatosteatosis, which is an early phase of alcoholic liver disorder. It may significantly contribute to the progressive development of fibrosis, which can ultimately lead to cirrhosis. Common symptoms of this condition include jaundice, fatigue, ascites and hepatic encephalopathy. The mild cases of this liver hepatitis are usually self-limiting. However, the severe cases carry a high mortality risk.

Alcoholic Hepatitis ICD-9 Code

The ICD-9 Code for this disease is 571.1.

Alcoholic Hepatitis Causes

This form of hepatitis occurs when the liver is damaged due to excessive drinking of alcohol. The exact mechanism in which alcohol damages the liver and the reason why it affects only a small minority of regular heavy drinkers is not known. It is, however, clear that the process responsible for breaking down ethanol (the alcoholic compound present in wine, beer and liquor) produces highly toxic chemical substances like acetaldehyde. Chemicals like these trigger inflammations that destroy the liver cells. Web-like scars or small tissue knots develop over time that replaces the healthy liver tissue, thereby interfering with the natural functioning of the liver. This irreversible scarring, known as Cirrhosis, is the last stage of this alcoholic liver hepatitis.

Heavy consumption of alcohol can give rise to liver disorders, and the dangers increase with the total duration of time as well as the amount of alcohol consumed. However, as many heavy drinkers do not develop the symptoms of cirrhosis or alcoholic hepatitis in their entire lives, it is believed that certain other factors may play an important part as well. These include:

Obesity

Individuals with increased body weight are found to be more prone to this condition.

Malnutrition

Many heavy drinkers are actually malnourished people. This is either because they eat food poorly or that the alcohol and its harmful byproducts made it difficult for the body to absorb the food properly and break down its nutrients. This is especially so in case of certain vitamins, proteins and fats. Lack of nutrients caused by both these instances contributes to the cellular damage of the liver.

Genetic factors

Mutations of certain genes can affect alcohol metabolism. This may increase the risk of developing an alcoholic liver disorder, along with other complications such as alcohol-related cancerous conditions. The exact genetic propensities have not been identified yet.

Other forms of hepatitis

Presence of other forms of hepatitis can increase the risk of developing cirrhosis and liver hepatitis in a person if he or she is also found to be a heavy drinker. Hepatitis C greatly increases the risk of development of serious liver conditions.

Alcoholic hepatitis is not a viral condition and hence it is not contagious.

Alcoholic Hepatitis Risk Factors

There are certain risk factors that might increase the chances of an individual of developing this disorder:

• The quantity of alcohol consumed can be described as the most essential factor in determining the possibilities of an alcoholic liver disease.
• Women are slightly more prone to developing alcoholic hepatitis as compared to men. The difference might actually be related to the processing of alcohol by the two sexes.
• Certain genetic influences might predispose an individual to Alcoholic hepatitis.
• Hispanic and African-American individuals carry a higher risk of developing this condition.
• The type of alcoholic beverage one prefers more to drink might also influence the possibility of having this disease. For example, spirits and beers are riskier compared to wine.
• Binge drinkers make up a vulnerable population, so are obese people. The combined effect of alcohol and obesity is much more damaging than either of them operating alone.

Alcoholic Hepatitis Pathophysiology

Some of the signs and pathological alterations, observed in liver histology, consist of:

Ballooning degeneration

The hepatocytes, under the influence of alcoholic change, frequently swell up with excess amounts of fats, proteins and water. All these proteins are generally exported into the bloodstream of an individual. Necrotic damage is accompanied by ballooning. The swelling can block the nearby biliary ducts, which leads to Diffuse cholestasis.

Mallory’s hyaline

It is a condition that is characterized by accumulation of pre-keratin filaments in hepatocytes. Although this symptom is not exactly limited to the alcoholic liver disease, it is frequently a notable feature.

Inflammation

Necrotic changes trigger neutrophilic invasion as well as presence of the cellular debris within lobules. Generally, the Kupffer cells remove the quantity of debris. However they become overloaded in an inflammatory setting, thereby allowing the other white blood cells to get into the parenchyma.

The presence of chronic liver disease might indicate:

• Fibrosis
• Cirrhosis

Symptoms of Alcoholic Hepatitis

A number of different signs and symptoms are commonly associated with alcoholic hepatitis. This may include:

• Malaise
• Enlargement of liver
• A modest rise in the levels of liver enzymes
• Development of ascites or fluid in the abdomen of patient

The cases of Alcoholic hepatitis may vary from being mild showing only liver enzyme elevations to severe liver inflammations that accompany development of jaundice, a prolonged prothrombin duration as well as liver failure. The severe instances are marked by either obtundation or dulled consciousness or a combination of prolonged prothrombin time and elevated bilirubin levels. In both of the severe categories, the mortality rate is 50% within the first 30 days from onset.

Other symptoms of the condition include:

• Nausea
• Vomiting
• Weight loss
• Loss of appetite
• Encephalopathy
• Malnourishment
• Abdominal tenderness

Alcoholic hepatitis is different from cirrhosis that occurs as a result of long-term alcohol consumption. Patients having chronic alcoholic liver disorder and alcoholic cirrhosis might get affected by alcoholic hepatitis. The condition of Alcoholic hepatitis does not itself lead to cirrhosis. However, cirrhosis is more prevalent in patients who have been heavy drinkers of alcohol for a long time. Some alcoholic individuals develop the condition of acute alcoholic hepatitis as a sort of inflammatory reaction to cells that are affected by the fatty change. However, this is not something that is directly related to dosage of alcohol. Certain people seem to be more prone to have this reaction than the others. This is known as alcoholic steato necrosis.

Alcoholic Hepatitis Diagnosis

The diagnosis of this disorder is made in patients with a history of chronic alcoholism who develops worsening results of liver function tests. This includes elevated bilirubin levels and aminotransferases. Ratio between aspartate aminotransferase and alanine aminotransferase (AST/ALT ratio) is generally 2 or more. Under most circumstances, the liver enzymes do not exceed that of 500. The alterations on a liver biopsy are vital in confirming clinical diagnosis of alcoholic hepatitis.

The various tests conducted to diagnose this condition include:

• Electrolyte tests
• Complete blood cell count
• Blood tests for excluding other factors of liver disease
• Imaging tests, such as CT scan, MRI scan or ultrasound of the liver
• Liver function tests, such as total bilirubin, albumin and international normalized ratio

Alcoholic Hepatitis Differential Diagnosis

While diagnosing this disorder, physicians should rule out the presence of the following conditions that show symptoms similar to Alcoholic Hepatitis:

• Hepatitis C
• Hepatitis B
• Chronic Pancreatitis

Alcoholic Hepatitis Treatment

The treatment of this disease begins with the ceasing of alcohol consumption of the patient. Without it, other modes of curing the condition would not have any effect on the patient. According to the clinical practice guidelines recommended by American College of Gastroenterology, alcoholic hepatitis should be treated by administering corticosteroids. A Child-Pugh score or a MELD score should be used for risk stratification of the patients.

Patients with Hepatic encephalopathy or the ones showing a modified Maddrey’s discriminant function score greater than 32 should be treated with prednisolone 40mg tablets daily for 4 weeks which should be then followed by taper.

Randomized controlled trial indicated that patients showing at least 1 of the symptoms such as fever, palpable tender hepatomegaly, leukocytosis, hepatic systolic bruit or hepatic encephalopathy and having a discriminant function score greater than 32 should be treated with an oral dosage of pentoxifylline 400mg three times daily for four weeks in order to prevent death.

Liver transplant

In cases of severe alcoholic hepatitis, a liver transplant surgery might be the only remaining option to evade death. The survival rates for a transplant are similar to that of the other types of hepatitis which is greater than 70% for 5-year survival.

However, most medical centers are somewhat reluctant to perform this transplant surgery as they fear that patients would resume their drinking habits once surgery is complete. For most alcoholic hepatitis patients, the disease itself is considered to be a contraindication for the liver transplantation procedure in most of the transplant centers of US.

Treatment for malnutrition

Doctors might recommend certain dietary practices that patients might need to follow to reverse the nutritional deficiencies that accompany alcoholic hepatitis cases. A sufferer might also be directed to a dietician for assisting with his or her needs who may recommend an increased amount of vitamins or nutrients in the diet.

Alcoholic Hepatitis Complications

The following complications might result from Alcoholic hepatitis:

• Coma
• Jaundice
• Liver cancers
• Kidney failure
• An enlarged spleen
• Hepatic encephalopathy
• Varices or enlarged veins
• Scarring of liver or cirrhosis
• Ascites or accumulation of abdominal fluids

Alcoholic Hepatitis Prognosis

The long-term outcome for untreated cases of this condition is very severe. However, proper treatment and cessation of alcohol consumption can lead to a better recovery. If a patient of chronic alcoholic hepatitis continues to drink, he or she would inevitably develop symptoms of cirrhosis and liver failure. Death rate associated with alcoholic hepatitis is close to 50% within 7 years. Encephaylopathy, prolonged PT, PTT, kidney failure and ascites are promoting factors of liver failure. In some cases, death can also result from shock that is induced by the fat thrombosis within the lungs, very low levels of blood sugar or acute pancreatitis. Hence it is extremely important that a patient completely gets rid of his or her alcoholic tendencies if he or she has to have a positive outcome of treatment.

Alcoholic Hepatitis Prevention

The following guidelines can help an individual to protect himself or herself from getting infected by this condition.

• Alcohol should be consumed in moderate amounts, if at all.
• Certain medications come with a warning that they are not to be consumed with alcohol. Medications such as these like the pain killer acetaminophen should never be mixed with alcohol.
• Hepatitis C greatly increases the chances of developing alcoholic hepatitis for heavy drinkers. Hence exposure to the viral agent causing this disorder should be avoided. Care should be taken to avoid drug contamination or transmission of Hepatitis C through sexual contact.

Severe cases of Alcoholic hepatitis might lead to death. Patients need to cease drinking alcohol immediately after diagnosis as this can help in survival and recovery.

References:

http://www.mayoclinic.com/health/alcoholic-hepatitis/DS00785

http://edition.cnn.com/HEALTH/library/alcoholic-hepatitis/DS00785.html

http://emedicine.medscape.com/article/170539-treatment

http://nyp.org/health/liver-alchep.html

http://medical-dictionary.thefreedictionary.com/alcoholic+hepatitis

http://www.liverfoundation.org/abouttheliver/info/alcohol/

http://www.fpnotebook.com/gi/Hepatitis/AlchlcHpts.htm

http://en.wikipedia.org/wiki/Alcoholic_hepatitis