Table 2.

Current recommendations for the diagnosis and treatment of acute alcoholic hepatitis (AH)

Disease/condition	Acute AH
Target audience	Gastroenterologists, hepatologists, primary care physicians, emergency medicine physicians, and other clinicians.
Target patient population	Adults with rapid onset of jaundice and elevated serum AST levels and a history of drinking more than 40 g (3 standard drinks) of ethanol daily for more than 1 year.
Criteria for diagnosis	Onset of jaundice within 8 weeks of last period of drinking Heavy drinking (> 40 g/day) for more than 6 months, usually for many years Serum bilirubin > 3.0 mg/dL Serum AST > 50 IU/L but < 400 IU/L Serum AST/ALT ratio > 1.5 Liver biopsy specimen showing macrovesicular steatosis, neutrophil infiltration, ballooning degeneration of hepatocytes, megamitochondria, and Mallory-Denk bodies is helpful but not required for the clinical diagnosis.
Assessing severity	Laboratory parameters are more reliable predictors of severe disease than clinical symptoms or signs or imaging criteria. Mathematical equations combining INR (prothrombin time) and serum bilirubin +/− creatinine, +/− age +/− WBC count are effective tools Maddrey discriminant function (MDF) > 32 predicts high mortality within 28 days. MELD score > 20 predicts a high mortality rate within 90 days. ABIC score category C predicts high 28- and 90-day mortality rates. Glasgow alcoholic hepatitis score of 9 predicts a high 28-day mortality rate.
Importance of recognition and treatment	Onset of jaundice indicates decompensation and is an ominous sign in all patients with chronic liver disease, particularly those with alcoholic liver disease. Although the name suggests a process that develops acutely, the majority of patients with AH have cirrhosis at the time of diagnosis of AH. Without treatment and abstinence from drinking alcohol, the mortality rate within 90 days is 40-50%.
Challenges related to treatment	The immune response, particularly neutrophil function, is impaired in patients with AH, placing them at risk of further decompensation following bacterial and fungal infections. Many treatments for AH focus on reducing inflammation through use of glucocorticoids or other drugs that suppress the immune system. Failure to maintain abstinence from drinking alcohol may lead to further deterioration in liver function.
Best Practice Advice (BPA)	BPA 1: Abstinence from drinking alcohol is the cornerstone of treatment for AH. BPA 2: Patients with jaundice and suspected AH should have cultures of blood, urine, and ascites, if present, to determine the presence of bacterial infections regardless of whether they have fever. BPA 3: Patients with AH who have jaundice require further evaluation to determine severity. Those with severe AH or inadequate social and medical support should be admitted to the hospital to encourage abstinence, restore adequate nutrition, and exclude serious infections. BPA 4: Imaging of the liver is warranted as part of the evaluation, but caution should be used in administering iodinated contrast dye, as it increases the risk of AKI. BPA 5: Patients with AH require a diet with 1-1.5 g protein and 30-40 kcal/kg body weight for adequate recovery. If the patient is unable to eat because of anorexia or altered mental status, a feeding tube should be considered for enteral feeding. Parenteral nutrition alone is inadequate. BPA 6: Severity and prognosis of AH should be evaluated using MDF, MELD, ABIC, or Glasgow scoring systems. Current treatments are based on this assessment. BPA 7: Presence of SIRS on admission is associated with an increased risk of multi-organ failure (MOF) syndrome. Development of MOF, usually due to infections developing after initial diagnosis of AH, is associated with a very high mortality rate. BPA 8: Nephrotoxic drugs, including diuretics, should be avoided or used sparingly in patients with AH, since AKI is an early manifestation of MOF. BPA 9: Patients with MDF > 32 or MELD score > 20 without a contraindication to glucocorticoid, such as hepatitis B viral infection, tuberculosis, or other serious infectious diseases, may be treated with methylprednisolone 32 mg daily, but the appropriate duration of treatment remains a subject of controversy. Methylprednisolone does not improve survival beyond 28 days, and the benefits for < 28 days are modest. BPA 10: Patients with a contraindication to glucocorticoids may be treated with pentoxifylline 400 mg three times daily with meals. Data regarding the efficacy are conflicting. BPA 11: Patients with severe AH, particularly those with a MELD score > 26 with good insight into their alcohol use disorder and good social support should be referred for evaluation for liver transplantation, as the 90-day mortality rate is very high. BPA 12: Patients with mild to moderate AH defined by a MELD score < 20 and MDF < 32 should be referred for abstinence counseling and prescribed a high protein diet supplemented with B vitamins and folic acid.
Important points to discuss with patients	Patients should be encouraged to abstain completely from drinking but offered support and encouragement even if they fail to achieve abstinence, as a reduction in alcohol consumption improves survival. Adequate nutrition, including calories and protein, is necessary for recovery from AH. Patients who drink alcohol at hazardous levels (> 40 g/day) should be advised to report jaundice as soon as it develops, since this symptom is a harbinger of serious injury.

ABIC, age, bilirubin, INR, creatinine; AKI, acute kidney injury; ALT, alanine aminotransferase; AST, aspartate aminotransferase; INR, international normalized ratio; MELD, Model for End-stage Liver Disease; SIRS, systemic inflammatory response syndrome; WBC, white blood cell.