Diagnostics

Suspect alcoholic hepatitis in patients with suggestive clinical features and a history of chronic heavy alcohol use.

Infections are common in patients with alcoholic hepatitis and are associated with a poorer prognosis. An infectious disease workup is recommended in all patients with alcoholic hepatitis.

• Liver chemistries in alcoholic hepatitis

  • AST: > 50 IU/L

  • Both AST and ALT: < 400 IU/L

  • AST:ALT ratio: > 1.5

  • Total bilirubin: > 3 mg/dL

• Additional liver studies

  • GGT: > 100 IU/L

  • ALP: ↑

  • INR: > 1.5

  • Albumin: < 3 g/L

• CBC

  • WBC: > 12,000/mm3

  • Platelets: ↓ or ↑

  • Macrocytic anemia (↓ hemoglobin with ↑ MCV)

• BMP: to assess for AKI and calculate severity scores

AST > ALT in alcoholic hepatitis: Remember “make a toAST with alcohol!”

Obtain imaging studies in all patients to rule out differential diagnoses (e.g., biliary obstruction, cholangitis ).

• RUQ ultrasound with Doppler (preferred): may show findings of fatty liver disease (e.g., steatosis, hepatomegaly, and periportal edema) and/or cirrhosis [1][4]

• CT or MRI abdomen: may show findings of fatty liver disease (e.g., decreased liver attenuation, heterogeneous steatosis) and/or cirrhosis

• Indications (not routinely recommended)

  • Unclear diagnosis because of the presence of confounding factors

  • Uncertain alcohol consumption

  • Recruitment to a clinical trial

• Technique: Transjugular liver biopsy is preferred. [1]

• Findings: signs of alcoholic steatohepatitis and/or cirrhosis

• Another alcoholic liver disease (e.g., decompensated cirrhosis)

• NAFLD

• Infection (e.g., acute cholangitis)

• Biliary obstruction (e.g., stones, tumors, strictures)

• Drug-induced liver injury (e.g., due to the use of acetaminophen, cocaine, prescription pharmaceuticals)

• Acute viral hepatitis (e.g., hepatitis A, hepatitis B, hepatitis C)

• Autoimmune hepatitis

• Metabolic liver disease

• Ischemic hepatitis (e.g., due to hypotension, shock, massive blood loss, or cocaine or other vasoconstrictor use)

AST > 400 IU/L should raise concern for drug-induced liver injury or ischemic hepatitis.