Alcoholic hepatitis (AH) is a severe form of liver injury characterized by the acute onset of jaundice and liver inflammation in people with a history of prolonged, heavy alcohol use. This condition is a serious medical crisis where the liver becomes inflamed and may begin to fail, resulting in a high risk of death. AH is generally not “cured” in the traditional sense, but rather managed and potentially reversed if caught early. While mild cases may fully resolve with complete abstinence, severe AH often leaves behind residual scarring, or cirrhosis. The 28-day mortality rate for severe alcoholic hepatitis ranges from 16% to 30%.
Absolute Necessity of Alcohol Cessation
Stopping alcohol consumption is the single most impactful step a person with alcoholic hepatitis can take and is required for liver recovery. Alcohol acts as the direct inflammatory trigger, creating toxic byproducts that damage liver cells and provoke inflammation. Removing alcohol immediately halts the driver of the injury, allowing the liver’s natural regenerative capacity to begin healing. Abstinence is the only intervention with demonstrated long-term benefit for improving liver function and reducing the risk of death.
The process of quitting is medically challenging and requires a structured approach to manage withdrawal. Abrupt cessation can trigger severe and potentially fatal withdrawal symptoms, including seizures and dangerously elevated blood pressure. A medical detoxification setting is necessary to safely manage these symptoms, which commonly begin within eight hours of the last drink. A multidisciplinary care team, including addiction specialists, provides behavioral counseling and pharmacological support. Medications such as acamprosate or baclofen may be used to help maintain long-term abstinence.
Acute Medical Stabilization
Patients presenting with severe alcoholic hepatitis require immediate, intensive medical treatment in a hospital setting. The primary goal of this acute care is to stabilize the patient, reduce systemic inflammation, and prevent early mortality. The first-line pharmacological treatment is often a course of corticosteroids, such as oral prednisolone at a dosage of 40 milligrams per day. Corticosteroids work by suppressing the inflammatory response that characterizes severe AH, thereby improving short-term survival.
Treatment response is closely monitored, often using the Lille score on day seven of therapy to determine if the patient is benefiting from the steroids. If the patient has contraindications to steroids, such as an active infection or gastrointestinal bleeding, an alternative treatment like pentoxifylline may be considered. Pentoxifylline has shown some benefit in preventing hepatorenal syndrome, a severe kidney complication. Aggressive nutritional support is also a standard part of acute stabilization, as severe AH patients are often malnourished, which worsens their prognosis. This nutritional plan involves providing high levels of calories and protein daily.
Managing the Aftermath of Chronic Liver Damage
Once the acute crisis is managed and the patient is stable and abstinent, the focus shifts to treating the chronic consequences of long-term liver injury, often involving established cirrhosis. Cirrhosis disrupts normal blood flow, leading to portal hypertension, which is elevated blood pressure in the vein leading to the liver. This increased pressure can cause varices, which are enlarged, fragile blood vessels in the esophagus and stomach. Management for varices involves prophylactic use of non-selective beta-blockers or endoscopic banding procedures to prevent life-threatening bleeding.
Portal hypertension also contributes to ascites, the accumulation of fluid in the abdominal cavity. This fluid retention is initially treated with dietary sodium restriction and a combination of diuretic medications. If ascites becomes excessive, paracentesis is performed to drain the fluid, which carries the risk of spontaneous bacterial peritonitis, a serious infection. Another consequence of reduced liver function is hepatic encephalopathy (HE), where toxins build up and affect brain function. Treatment for HE is directed at lowering these toxin levels in the bloodstream.
Cancer Surveillance
Patients who have developed cirrhosis as a result of AH must also undergo regular surveillance for hepatocellular carcinoma. This is the most common form of liver cancer and typically involves an ultrasound every six months.
End-Stage Disease and Transplantation
For a significant number of patients with severe alcoholic hepatitis, the liver damage is too extensive to be reversed by medical therapy alone, leading to end-stage liver failure. Patients who fail to respond to initial medical treatment have a poor prognosis, with mortality rates reaching as high as 70% at six months. In these cases, a liver transplant becomes the only curative option for long-term survival. Historically, transplant centers enforced a mandatory six-month period of sustained sobriety before a patient could be placed on the waiting list.
The reasoning behind the six-month rule was to allow time for the liver to potentially recover and to evaluate the patient’s commitment to long-term abstinence. However, this policy often meant that the sickest patients with severe AH died while waiting. Recent studies have challenged this rigid requirement, showing favorable outcomes for early transplantation in carefully selected patients unresponsive to medical treatment. These studies demonstrate that one-year survival rates for early transplant recipients are high, often around 94%. The long-term prognosis for AH patients who receive a successful transplant is similar to that of other recipients, offering a life-saving option.