Alcoholic liver disease (ALD) is one of the leading causes of morbidity and mortality in the U.S. and worldwide. Three hepatologists discussed the management of patients with alcoholic hepatitis (AH) and how to diagnose and treat alcohol use in patients with ALD during an AASLD symposium on Monday, May 8, at DDW® 2017.
According to Vijay Shah, MD, chair of gastroenterology and hepatology at the Mayo Clinic, Rochester, MN, cirrhosis mortality is highest in Africa and Asia, with mortality rates of 36.4 per 100,000 in Africa and 26.8 per 100,00 in Asia. The cirrhosis-related mortality rate in the U.S. and Canada is 9.4 per 100,000, he said.
The initial evaluation for alcohol hepatitis should include a history and physical. Clinicians should look for a recent history of heavy alcohol use, recent onset or worsening of jaundice, and toxic effects of alcohol use such as ascites, variceal bleeding or sarcopenia. Lab markers include serum bilirubin >3mg/dl, AST>ALT (2X upper limit and <400 IU/liter) and AST/ALT ratio >1.5.
Clinicians should exclude other causes of liver disease and jaundice, such as drug-induced liver injury, viral hepatitis and autoimmune disorders. If the patient’s alcohol history is not clear and jaundice occurred more than three months prior to the exam, a transjugular liver biopsy should be performed. A discriminant function score less than 32 predicts a 50 percent chance of mortality.
Severe AH is treated with corticosteroids. Contraindications to corticosteroid use include uncontrolled diabetes, active sepsis, renal failure, GI bleeding and pancreatitis. Patients with mild AH can be treated with nutritional supplements. Studies have shown that a high calorie intake correlates with survival.
Gene Im, MD, assistant professor of medicine at the Icahn School of Medicine at Mount Sinai, New York, NY, discussed the role of liver transplantation in the treatment of AH, noting that the role continues to evolve.
“Early liver transplantation for severe AH can be successful in carefully selected candidates with good insight and the first decompensating event,” Dr. Im said. “However, for most AH patients the prognosis is poor, so prevention is key.”
Mortality in AH patients generally occurs within three months of diagnosis, he said. Since medical therapies are limited to corticosteroids, liver transplantation may be the only option for patients with severe AH. Early liver transplantation improves six-month survival in patients with severe AH, Dr. Im said.
Dr. Im estimated that 85 percent of medical centers in the U.S. and Europe require candidates for transplant to abstain from alcohol for six months prior to being placed on a wait list for a liver transplant.
“However, exceptional patients with ALD who have not been abstinent for six months and yet whom the program believes are good candidates for liver transplantation can be considered,” he added.
The key inclusion criteria for a liver transplant include no response to medical therapy, severe AH as the first liver decompensating event, supportive family members, the absence of co-existing or psychiatric disorders, and the patient’s commitment to lifelong alcohol abstinence.
Ramon Bataller, MD, PhD, chief of hepatology at the University of Pittsburgh, PA, discussed methods to diagnose and treat alcohol use in patients with ALD, advising clinicians to “start dealing with the alcohol problem from the very first ALD patient visit, even if the patient has reached abstinence.”
Dr. Bataller advised physicians to provide counseling for alcoholism in the first visit either by counseling the patient themselves or referring the patient to an addiction specialist. Studies indicate that about 50 percent of patients treated for alcoholism go back to drinking, Dr. Bataller said.
The physical signs of chronic alcohol use include dupuytren, rhinophyma, vascular ectasia, malar erythema and parotid hypertrophy. Other signs include malnourishment, sarcopenia, cognitive impairment (a flat effect), and peripheral neuropathy. Alcoholism is often associated with cigarette smoking, poor hygiene with social isolation and fractures, Dr. Bataller said.
“Always suspect alcohol as a cause of liver disease,” he advised. “Build trust in your relationship with the patient before asking about alcohol use. Be sensitive to the stigma of alcoholism. Ask family members about the patient’s alcohol use.”