Alcohol-associated hepatitis (AAH)

The symptoms of alcohol-associated hepatitis can vary, ranging from mild to severe. They include: 

• Jaundice: This is a hallmark symptom, indicating liver dysfunction.
• Abdominal pain: This is more prominently felt in the upper right side of the abdomen.
• Fatigue: Owing to compromised liver function, the affected individuals feel excessively tired or weak.
• Loss of appetite: This is often associated with nausea (urge to vomit) or vomiting.
• Fever: Mild to moderate fever can occur in the case of AAH.
• Ascites: Fluid buildup in the abdomen is often seen in advanced cases of AAH.
• Hepatomegaly: AAH causes enlargement of the liver, which can result in discomfort or a sensation of fullness.
• Confusion or mental changes: In severe cases, particularly in case of liver failure, confusion or disorientation can occur (hepatic encephalopathy); the person might even slip into a coma.
• Easy bruising or bleeding: Affected individuals become susceptible to easy bruising or bleeding owing to impaired clotting function of the liver.
• Liver failure: In severe cases, AAH can rapidly progress to liver failure, which is a medical emergency.

AAH is diagnosed using several strategies (clinical evaluation, laboratory tests, and imaging). These include:

• Clinical history: Information regarding the quantity, frequency, and duration of alcohol use—along with other risk factors—is collected.
• Physical examination: Patients are evaluated for signs of liver damage (jaundice, hepatomegaly (enlarged liver), ascites, or mental status changes) are observed.
• Laboratory tests:
  • Liver function tests: In AAH, AST levels are often more elevated than ALT levels, and the AST to ALT ratio is typically greater than 2.
  • Complete blood count (CBC) test: Reduced counts of white blood cells (leukopenia) and platelets (thrombocytopenia) may be observed in AAH.
  • Coagulation tests: Prolonged prothrombin time (PT) or increased international normalised ratio (INR) can indicate impaired liver function.
  • Serum bilirubin: Elevated bilirubin levels indicate AAH with jaundice.
  • Albumin levels: Extremely low albumin levels are a sign of liver failure.
• Imaging:
  • Ultrasound: This modality helps assess the liver size, texture, and any evidence of cirrhosis or fatty liver; however, it cannot definitively diagnose AAH.
  • CT or MRI: These modalities may be used to rule out other liver diseases or complications.
• Liver biopsy: A liver biopsy may be performed to confirm the diagnosis, particularly in uncertain cases, and to assess the extent of liver damage (inflammation, fibrosis, or cirrhosis).
• Rule out other causes: As hepatitis can have multiple causes, tests need to be performed to rule out other types of hepatitis (e.g., hepatitis B, C, A, E).

The treatment for AAH aims to manage symptoms, prevent complications, and address the underlying alcohol use disorder.

• Support groups, counselling, or alcohol rehabilitation programs: These may be necessary to help individuals stop drinking.
• Medications:
  • Corticosteroids (e.g., prednisolone): These are often used to manage moderate to severe cases of AAH. However, they are not effective in all cases and may have side effects, particularly in patients with underlying infections or liver failure.
  • Pentoxifylline: This medication may help reduce the risk of renal failure in patients with severe AAH.
• Liver transplantation: In patients with severe, life-threatening AAH for whom management using medications might not work or who have progressed to liver failure, a liver transplant may be necessary.
• Nutritional support: Malnutrition is common in AAH, so providing adequate nutrition (vitamin B supplementation) is essential to prevent complications such as Wernicke-Korsakoff syndrome (which is due to vitamin B deficiency). Patients may require enteral nutrition (feeding through a tube) or parenteral nutrition (intravenous (IV) feeding) in severe cases.
• Management of complications:
  • Diuretics (e.g., spironolactone): These may be used to reduce fluid buildup in the abdomen (ascites).
  • Therapeutic paracentesis (removal of fluid): This might need to be performed in severe cases of ascites.
  • Lactulose: This can be used to lower blood ammonia levels and reduce confusion in case of hepatic encephalopathy.
• Supportive care: In severe cases, particularly when liver failure is imminent, hospitalisation and intensive care may be required to monitor vital signs, kidney function, and prevent infections.
• Liver transplantation: Liver transplantation is considered for individuals with acute AAH and severe liver failure who do not improve with medical treatment.

Limiting alcohol consumption is the key to preventing the occurrence of AAH. For individuals with existing liver disease, it is critical that alcohol consumption be avoided completely to prevent further liver damage.