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Alcohol-related liver disease and alcoholic hepatitis
Alcohol-related liver disease runs from fatty liver through alcoholic hepatitis to cirrhosis; severe alcoholic hepatitis (Maddrey 32 or more or MELD above 20) is treated with prednisolone 40 mg for 28 days when there is no infection or bleeding, and the most important treatment at every stage is stopping drinking.
Why it matters in the exam
The question presents a heavy drinker with jaundice that appeared in recent weeks, low-grade fever, an enlarged tender liver and leukocytosis. Laboratory clues: AST higher than ALT by 1.5–2 times or more, both usually below 400, bilirubin above 3 mg/dL, and a high GGT and MCV. The candidate must calculate severity (Maddrey or MELD), exclude infection (cultures, ascitic tap) and bleeding, and only then start steroids in a severe case. On day 7 the Lille score is calculated: above 0.45 = no response, and steroids are stopped. Pentoxifylline is not recommended.
Beyond the acute attack, questions test treatment of alcohol use disorder in a patient with liver disease: baclofen and acamprosate are relatively safe, while disulfiram and naltrexone are avoided in advanced liver disease. Every patient receives thiamine (to prevent Wernicke), nutritional support and assessment for cirrhosis and its complications. For selected non-responders, early liver transplant is an option in experienced centres. A well-known distractor: an AST of 1500 is not typical of alcoholic hepatitis — such values point to paracetamol, ischaemia or a virus.
Key points
- AST/ALT above 1.5, both below 400, bilirubin above 3 mg/dL — alcoholic hepatitis.
- Severe: Maddrey 32 or more or MELD above 20 → prednisolone 40 mg for 28 days.
- Exclude infection and bleeding before steroids.
- Lille on day 7: above 0.45 → stop.
- Stop drinking, thiamine, baclofen or acamprosate.
Summary table
| Stage | Finding | Action | Exam note |
|---|---|---|---|
| Fatty liver | Mildly raised enzymes, enlarged liver | Stop drinking — reversible | Very common |
| Alcoholic hepatitis | New jaundice, AST/ALT above 1.5, both below 400, bilirubin above 3 mg/dL | Maddrey or MELD; exclude infection and bleeding | AST above 1000 → another diagnosis |
| Severe hepatitis | Maddrey 32 or more or MELD above 20 | Prednisolone 40 mg a day for 28 days | Not with active infection or bleeding |
| Steroid response | Lille score on day 7 | Above 0.45 → stop | Pentoxifylline not recommended |
| Addiction treatment | Patient with liver disease | Baclofen or acamprosate | Avoid disulfiram and naltrexone in advanced disease |
| Support | Every patient | Thiamine, nutrition, cirrhosis follow-up | Early transplant in selected patients |
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Sources
- ACG Clinical Guideline: Alcohol-Associated Liver Disease, 2024 — Alcoholic hepatitis: diagnosis, severity scores, corticosteroids and abstinence treatment
- EASL Clinical Practice Guidelines: Management of alcohol-related liver disease, 2018 — Spectrum, prognosis and treatment
- Harrison's Principles of Internal Medicine, 21st edition (2022) — Alcohol-Associated Liver Disease
Sources are given for further reading; the text is written afresh and not copied from them.
Reviewed by the Examqo AI Professor · 2026-11-02. The text may contain errors; when in doubt, check the source.