Summary

Background

The assessment of alcoholic hepatitis remains controversial. Several scores have been developed or used for this purpose.



Aim

To study the use of the Glasgow Alcoholic Hepatitis Score (GAHS), the Discriminant Function (DF), Model for End-Stage Liver Disease (MELD) and the ABIC (age, bilirubin, INR and creatinine) scores as well as scores to assess corticosteroid response in the management of alcoholic hepatitis.



Methods

A total of 182 patients were studied prospectively. The GAHS, MELD, ABIC and DF scores were recorded on admission and serially over the first week of hospital management. Treatment with corticosteroids or pentoxifylline was considered if the GAHS was ≥9.



Results

There were no differences in outcome between favourable scores as per recommended cut-off points. Patients with a GAHS<9 had similar outcome whether their MELD, DF or ABIC scores were favourable or unfavourable. Treated patients with a GAHS≥9 had a significantly better 90-day outcome than those who did not: 58% and 30% respectively, P = 0.01; HR 0.33 (0.14, 0.78).



Patients treated with corticosteroids who had a fall in bilirubin of 25% after a week of treatment had an improved survival: 82% compared with 44% [P = 0.0005: HR 3.70 (1.77, 7.73)]. The Lille Score or a 25% fall in bilirubin had greater sensitivities than an early change in bilirubin level (95% and 90% compared with 58%) to assess treatment response.



Conclusions

In this single-centre study, a GAHS ≥9 identified patients who may benefit from treatment of alcoholic hepatitis. Intention-to-treat randomised-controlled trials using a GAHS ≥9 as the threshold for treatment are needed to validate these findings. Response to corticosteroids can be assessed using the Lille Score or by a 25% fall in bilirubin.

https://onlinelibrary.wiley.com/doi/pdf/10.1111/apt.12414

The management of alcoholic hepatitis: a prospective comparison of scoring systems

Rising levels of alcohol consumption in the UK are leading to substantial increases in morbidity and mortality from liver disease. Drinking is starting at an earlier age with binging an increasing common pattern, and women are overtaking men in the consumption. Manifestations of liver damage range from fatty liver to end-stage cirrhosis, but it is the increasing number of cases presenting with an acute alcoholic hepatitis (AAH) that are the cause for greatest concern. Development of well-validated prognostic scoring systems (Maddrey Modified Discriminant Function, Glasgow Alcohol Score) makes it possible to select those patients with AAH who are most likely to respond to corticosteroids. The results of early pilot studies of a number of anti-TNF agents are encouraging and with infliximab, reduction in portal pressure has been demonstrated to be consequent on controlling inflammatory processes in the liver. For those deteriorating to the stage of liver failure, artificial liver support with MARS is of value in correcting major pathophysiological disturbances and as a bridge to liver transplantation, the results of which both for end-stage alcoholic cirrhosis and for AAH--of which there is limited experience, are excellent. Even as the stringent regulatory measures needed to control rising alcohol consumption are introduced by government, the burden of liver disease in the UK will remain high for years to come.

/pdf/the-pervading-influence-of-alcoholic-liver-disease-in-2r6suqu66i.pdf

The pervading influence of alcoholic liver disease in hepatology

Objective: There is a lack of data concerning Turkish patients with alcoholic hepatitis (AH). The aims of the present study were to present the clinical characteristics of hospitalized AH patients and to compare the predictive ability of Maddrey’s discriminant function (DF) score, Model for End-Stage Liver Disease (MELD) score, Glasgow AH (GAHS) score and age, bilirubin, International Normalized Ratio (INR), and creatinine (ABIC) score on in-hospital mortality.
Methods: The DF score and clinical data of 34 patients with AH admitted from 2008 to 2014 were reviewed from patient’s files. Scores for MELD, GAHS and ABIC were then retrospectively calculated. A comparison of scores was obtained using area under the receiver operating characteristics curves to predict in-hospital mortality.
Results: In-hospital mortality was calculated at 23.5% (8/34). Treatment with corticosteroids and/or pentoxifylline was started in 18 patients with DF score ≥ 32; however, seven of them died (7/18, 39%). No significant differences were found between DF, MELD, GAHS and ABIC scores for predicting in-hospital mortality (p>0.05).
Conclusion: DF score, which is easier and more practical, can be used in clinical practice to predict in-hospital mortality because other scores have no statistical superiority. The response to corticosteroid and/or pentoxifylline treatment in patients with a DF score ≥ 32 was poor in Turkish AH patients.

A Comparison of Prognostic Scoring Systems in Turkish Alcoholic Hepatitis Patients

All chronic and excessive consumer of alcohol with recent jaundice should be assessed using a Maddrey's score for severe acute alcoholic hepatitis. Corticosteroids are the first line of treatment, associated with an appropriate nutritional support and alcohol abstinence. Corticosteroids plus N-acetylcysteine combination improves short-term survival over corticosteroids alone, and could be proposed as a first line therapy. The response to treatment is evaluated at the 7th day of treatment, with the Lille model≤0.45. Prognostic of non-responders to corticosteroids with Lille model>0.45 is dramatically low with 23% survival at 6 month. Early liver transplantation in a selected group of patients with non-response to corticosteroids significantly improves 6th month and long-term survival.

Severe acute alcoholic hepatitis

Tout patient consommateur chronique et excessif d’alcool avec un ictere recent doit etre evalue par le score de Maddrey a la recherche d’une hepatite alcoolique aigue severe. Les corticosteroides representent le traitement de premiere ligne, associes a un soutien nutritionnel adapte et a une abstinence alcoolique. La combinaison corticosteroides plus N -acetylcysteine (perfusee pendant les cinq premiers jours) ameliore la survie a court terme par rapport aux corticosteroides seuls, constituant une option therapeutique de premiere ligne. La reponse au traitement est evaluee au septieme jour par le modele de Lille inferieur ou egal a 0,45. Le pronostic des patients non repondeurs aux corticosteroides avec un modele de Lille superieur a 0,45 est sombre avec une survie de 23 % a six mois. Pour des patients non repondeurs aux corticosteroides et selectionnes, la transplantation hepatique precoce ameliore significativement la survie a six mois et a long terme.

/pdf/hepatite-alcoolique-aigue-severe-lrt5fwujr8.pdf

Hépatite alcoolique aiguë sévère

950 tolerance and efficacy of the mars system in patients with severe alcoholic hepatitis non-responders to steroids: a pilot study

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950 tolerance and efficacy of the mars system in patients with severe alcoholic hepatitis non-responders to steroids: a pilot study