Show notes
Episode two moves along the alcohol continuum to alcohol-associated liver disease, one biology read across steatosis, steatohepatitis, and cirrhosis, then zeroes in on the acute superimposed syndrome of severe alcoholic hepatitis. The organizing idea: severe disease is defined by a Maddrey above thirty-two or a MELD over twenty, treated with prednisolone only after infection is excluded, with the day-seven Lille score as the binary decision to continue or stop. It works through the AST-greater-than-ALT lab signature, the ethanol-metabolism mechanism that drives it, and the drug interactions that follow. The close is early transplant for selected steroid nonresponders, which retired the old six-month sobriety rule in favor of a structured psychosocial assessment.
Topics covered
Three-stage spectrum: steatosis, steatohepatitis, cirrhosis
Ethanol metabolism, the NADH shift, and drug interactions
Risk modifiers: sex, genetics, and the acetaldehyde variant
The AST-greater-than-ALT lab pattern
Severe alcoholic hepatitis and the consensus diagnostic criteria
Maddrey and MELD severity thresholds
Prednisolone therapy and mandatory infection screening
The day-seven Lille response decision
Early transplant selection criteria
Key decisions
Diagnose probable alcoholic hepatitis from jaundice within two months, heavy use for at least six months, an AST between fifty and four hundred with a ratio over one and a half, and a bilirubin over three, letting you skip biopsy in the typical patient.
Define severe disease by a Maddrey discriminant function above thirty-two or a MELD over twenty; MELD-Na is not used here.
Expect an AST-to-ALT ratio above one and a half, often above two, with both under four hundred; transaminases over four hundred in a drinker signal something on top of alcohol, classically acetaminophen or ischemic hepatitis.
Give prednisolone forty milligrams daily for up to twenty-eight days, but only after culturing blood, urine, and ascites and imaging the chest, because serious infections were roughly twice as common on steroids; AKI with creatinine above two and a half, uncontrolled infection, and GI bleeding defer or contraindicate them.
Calculate the Lille score at day seven: under about half is a responder who completes the course, while at or above that threshold is a nonresponder who stops steroids because continuing adds infection risk without survival benefit.
Add N-acetylcysteine as an adjunct and give nutrition at thirty to forty kilocalories per kilogram and one and a half grams of protein per kilogram by mouth or nasogastric tube, avoiding parenteral nutrition for infection risk.
Refer steroid nonresponders with first decompensation, strong support, no prior treatment failure, and clear insight for early transplant; the six-month sobriety rule is retired, and post-transplant use acamprosate and baclofen for alcohol use disorder.
For the full chapter with MCQs, tables, and primary-guideline references, visit www.boardpearls.com.
Questions or feedback: [email protected].
(00:00) - Introduction and the organizing idea
(00:29) - The three-stage spectrum and reversibility
(01:22) - Mechanism and drug interactions
(03:39) - The AST-greater-than-ALT lab pattern
(04:34) - Severe alcoholic hepatitis and its criteria
(06:12) - Steroids, the trial, and infection screening
(07:36) - The day-seven Lille decision
(09:12) - Early transplant and retiring the six-month rule
(10:36) - Selection criteria for early transplant