HPI:

43 year-old female with a history of alcohol abuse and alcoholic hepatitis, presenting after referral from breast clinic for abnormal labs (notable for total bilirubin 18.1). The patient was well until two weeks ago when she noted increasing fatigue associated with morning nausea/vomiting (non-bloody) as well as yellowing of skin and eyes. She also reports darkening of urine, but no dysuria, change in volume of urine, or visible blood. She also denies fevers/chills, increased abdominal girth, abdominal pain, changes in bowel habits or bloody/dark stools.

She reports drinking 1 pint of vodka daily for the past 15 years, and perhaps more in the past 3 weeks. Her last drink was in the morning on the day of admission, she denies any history of seizures and reports withdrawal symptoms (tremor, nausea) relieved with more alcohol. She currently denies anxiety/agitation, tactile/visual/auditory hallucinations.

The patient was in breast clinic for evaluation of a painful breast mass which developed after biopsy of a lesion which was ultimately found to be benign. The patient noted the mass was growing in size and becoming more painful over the past month.

Physical Exam:

VS:	T	98.9	HR	104	RR	19	BP	117/67	O2	99% RA
Gen:	Well-appearing obese female in no acute distress
HEENT:	PERRL, marked scleral icterus, sublingual icterus, MMM, no lesions
CV:	Tachycardia, regular rhythm, normal S1/S2, no M/R/G
Lungs:	CTAB, no crackles/wheezing
Abd:	+BS, soft, non-distended, liver edge palpated 6cm below costal margin, irregular texture slightly tender to palpation, spleen not palpated, no fluid wave or shifting dullness, no rebound/guarding.
Ext:	Warm, well-perfused, 2+ pulses (DP/PT), slight yellowing.
Skin:	Vascular spiders on anterior chest, left breast with 5x5cm ecchymosis and tender underlying mass, no erythema, warmth, skin dimpling, nipple discharge.
Neuro:	AAOx4, CN II-XII intact, no tremor noted, gait normal.

Labs/Studies:

1mo prior to admission:

• AST/ALT/AP/TB: 444/77/234/2.5

Day 1:

• AST/ALT/AP/TB: 185/61/184/18.1
• PT/PTT/INR: 14.7/37.0/1.2

Day 4:

• AST/ALT/AP/TB: 142/50/153/25.5
• PT/PTT/INR: 20.1/38.9/1.7

Imaging:

Abdominal US

1. Markedly echogenic and enlarged liver with a nodular surface of cirrhosis.
2. Markedly blunted hepatic vein waveforms commonly seen due to decreased hepatic parenchymal compliance although other etiologies causes of obstruction to hepatic venous outflow.
3. Splenomegaly.

Assessment/Plan:

44F hx EtOH abuse, alcoholic hepatitis, presenting with acute alcoholic hepatitis.
# Alcoholic hepatitis: Rapid onset of jaundice, tender hepatomegaly, and elevation of transaminases (AST > ALTx2) in the setting of chronic alcohol use suggestive of alcoholic hepatitis. Initial Maddrey discriminant hepatic function (mDH) score 37 suggestive of severe disease with high short-term mortality. Initiated trental 400mg p.o. t.i.d.
# EtOH withdrawal: Last drink <24h ago, monitor for signs of withdrawal, treat with Ativan per withdrawal protocol. # Cirrhosis: Newly diagnosed on abdominal ultrasound. Complicated by coagulopathy, and likely portal hypertension given splenomegaly/thrombocytopenia. Plan for outpatient screening EGD and continued GI follow-up. # Breast mass: Likely hematoma 2/2 biopsy associated given increased size associated with progression of coagulopathy/thrombocytopenia. Outpatient ultrasound and follow-up scheduled. # Anemia: Macrocytic, potentially related to vitamin deficiency vs. bone-marrow suppression associated with chronic alcohol use. Start thiamine/folate/multivitamin. # FEN/GI/PPx: Encourage p.o. intake (2g sodium restriction), continue ondansetron p.r.n. nausea/vomiting, obtain nutrition consult.

Hospital Course

Patient’s liver function continued to decline as evidenced by worsening coagulopathy and increased serum bilirubin. mDH had increased to 58 by day four of hospitalization and steroids were added.

Pathophysiology of Alcoholic Hepatitis: ¹

Ethanol promotes translocation of bacterial components (lipopolysaccharide) across the intestinal wall, into the portal venous system and liver. These trigger a local and systemic inflammatory response which leads to hepatocellular injury and systemic effects such as fever, anorexia and weight loss.

Evaluation of Alcoholic Hepatitis: ^1,2

Clinical features:

• Rapid onset jaundice
• Tender hepatomegaly
• Fever
• Ascites
• Proximal muscle loss
• Encephalopathy

Labs:

• AST > ALT (x2), generally < 300IU/mL
• Leukocytosis
• ↑Total serum bilirubin
• ↑INR
• ↑Creatinine associated with poor prognosis

Other studies:

• Screening for infection: PNA, UTI, SBP
• Abdominal US to evaluate hepatic abscess, HCC, extrahepatic biliary obstruction

Management of Alcoholic Hepatitis: ^1,2

Grading Severity:

• Maddrey’s discriminant function
• Glasgow score
• Lille score (assess response to corticosteroids after 1wk)

Treatment:

• Immediate and lifetime abstinence from alcohol
• Trental 400mg p.o. t.i.d.
• Prednisolone 40mg p.o. daily (controversial, some benefit in subgroup with Maddrey > 32)
• Ascites: Sodium restriction, diuretics
• Encephalopathy: Lactulose, rifaximin
• Hepatorenal syndrome: albumin, vasopressors
• Nutritional support

Interpretation of Liver Function Tests: ³

Disorder	Bilirubin	AST/ALT	AΦ	Albumin	PT
Hemolysis Gilbert	↑(indirect) No bilirubinuria	–	–	–	–
Acute hepatocellular necrosis	↑	↑ALT > AST > 500IU	↑	–	– (poor prognosis if elevated)
Chronic liver disease	↑	↑ < 300IU	↑	↓	↑
Alcoholic hepatitis	↑	↑ AST:ALT > 2	↑	↓	↑
Intra- extra-hepatic cholestasis	↑	↑ < 500IU	↑↑ (>4x normal)	–	–

Features of Components of Liver Function Tests: ^3,4

References:

1. Lucey, M. R., Mathurin, P., & Morgan, T. R. (2009). Alcoholic hepatitis. The New England journal of medicine, 360(26), 2758–2769. doi:10.1056/NEJMra0805786
2. Sohail, U., & Satapathy, S. K. (2012). Diagnosis and management of alcoholic hepatitis. Clinics in liver disease, 16(4), 717–736. doi:10.1016/j.cld.2012.08.005
3. Kaplan MM. Chapter 302. Evaluation of Liver Function. In: Longo DL, Fauci AS, Kasper DL, Hauser SL, Jameson JL, Loscalzo J, eds. Harrison’s Principles of Internal Medicine. 18th ed. New York: McGraw-Hill; 2012.
4. Johnston, D. E. (1999). Special considerations in interpreting liver function tests. American family physician, 59(8), 2223–2230.