Alcoholic Hepatitis

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Epidemiology

In the United States, recent estimates suggest that 67% of the adult population drinks alcohol [1]. The prevalence of alcohol dependence, as defined by the Diagnostic and Statistical Manual of Mental Disorders, fourth edition, has remained low, however, at 4%, according to the 1990 and 1995 National Alcohol Survey [2]. The prevalence is higher in men (6%) than in women (2%). The prevalence of alcohol dependence is particularly high among young adults (18 to 29 years of age), those who never

Pathogenesis

The wide range of individual susceptibility to alcoholic liver disease could be explained by the genetic polymorphism of various metabolic and enzymatic pathways that modulate ethanol metabolism [3]. Such metabolic pathways generate reactive oxygen species that are potent inducers of lipid peroxidation, which in turn causes hepatocyte death by necrosis or apoptosis. High levels of endotoxemia also have been documented among patients who have acute alcoholic hepatitis, probably because of

Pathology

Acute alcoholic hepatitis is characterized morphologically by steatosis, steatohepatitis with polymorphonuclear or mixed infiltration, hepatocyte ballooning, intracytoplasmic Mallory bodies, and fibrosis with perivenular, perisinusoidal, and pericellular distribution (Fig. 1) [8]. Steatosis is mainly macrovesicular and is most prominent in the centrilobular regions. Hepatocytes appear bloated and may have megamitochondria. Mallory bodies are intracellular, eosinophilic, ropelike deposits formed

Clinical features

Patients who have alcoholic hepatitis may be asymptomatic, have only hepatomegaly, perhaps a dull ache over the liver, or have a full-blown picture with tender hepatomegaly, jaundice, fever, malaise, anorexia, and nausea and vomiting. Many have lost a considerable amount of weight, and malnutrition can be seen in about 90% of cases. On physical examination, there are usually florid stigmata of chronic liver disease such as spider nevi and facial telangiectasias. Palmar erythema, Dupuytren's

Prognosis

The mortality of hospitalized patients who have alcoholic hepatitis varies widely. The short-term (<3 months) mortality ranges from 15% to 55% for those who have mild and severe alcoholic hepatitis, respectively [14], [15], [16], [17]. Thus, it is paramount to identify those patients who might benefit from aggressive intervention as well as those for whom the therapeutic benefit-to-risk ratio is unfavorable [18]. Assessing severity of disease in patients who have alcoholic hepatitis is useful

Management and treatment issues

A myriad of treatment options for alcoholic hepatitis have been evaluated over the years, but current therapy still focuses predominantly on supportive care.

Summary

Alcoholic hepatitis still remains a difficult-to-treat clinical condition. Although the Maddrey Discriminant Function traditionally has been used for prognosticating, several newer clinical scoring systems, including MELD and GAHS, have been developed but still require prospective validation. Abstinence, close monitoring, and supportive care are the standard of care in alcoholic hepatitis. Treatment with corticosteroids has been studied in several clinical trials with conflicting results;

Acknowledgements

The authors most sincerely thank Dr. A. J. Demetris, Professor of Transplant Pathology at the University of Pittsburgh, for kindly providing the composite histopathology slide and the legend for Fig. 1.

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