Alcoholic hepatitis is a clinical syndrome with a broad range of manifestations, from vague malaise to fulminant liver failure. Alcoholic hepatitis should be suspected in patients with prolonged heavy alcohol use and recent-onset jaundice, fever, leukocytosis, and tender hepatomegaly. Characteristic findings from include and hyperbilirubinemia. A diagnosis of acute alcoholic hepatitis requires consideration of confounding factors, including differential diagnoses of alcoholic hepatitis, uncertain alcohol use, and atypical laboratory results. Laboratory-based prognostic scores (e.g., Maddrey discriminant function and MELD scores) can be used to assess severity and short-term prognosis and guide management. Complete abstinence from alcohol is advised for all patients and is considered the most effective intervention. Supportive management includes nutritional support, monitoring for alcohol withdrawal syndrome, and treatment for alcohol use disorder. Patients with severe alcoholic hepatitis may benefit from pharmacotherapy with glucocorticoids or, in selected cases, early liver transplantation. Patients with no response to glucocorticoids who are not candidates for early liver transplantation should be referred for palliative care.
- Incidence: ∼ 0.8% of all hospitalizations in the US per year 
- Survival 
Epidemiological data refers to the US, unless otherwise specified.
- Acute hepatitis: tender hepatomegaly, acute jaundice, malaise, nausea, anorexia, fatigue, fever, weight loss, tachypnea
- Acute alcohol withdrawal: tremor, agitation, tachycardia, ,
- Long-term alcohol use: rhinophyma, Dupuytren contracture, sarcopenia, temporal muscle wasting
- Cirrhosis : (e.g., jaundice, ascites, palmar erythema, spider angiomata)
Acute alcoholic hepatitis may be reversible in mild cases. 
These recommendations are consistent with the 2019 American Association for the Study of Liver Diseases (AASLD) and 2018 American College of Gastroenterology (ACG) clinical guidelines. 
- Use the consensus definitions for alcoholic hepatitis to establish a definite, probable, or possible diagnosis.
- Obtain laboratory and imaging studies to support the diagnosis and rule out other causes of hepatitis and jaundice.
- Perform a thorough infectious disease workup guided by clinical suspicion.
- Assess severity using the Maddrey discriminant function or MELD score.
- Identify patients with alcohol use disorder (e.g., using the score).
Consensus definitions for alcoholic hepatitis 
The AASLD recommends classifying patients according to the consensus definitions.
- Clinical diagnosis of alcoholic hepatitis
- Confounding factors
Initial studies 
- Liver chemistries in alcoholic hepatitis
- Additional liver studies
- BMP: to assess for AKI and calculate severity scores
Obtain imaging studies in all patients to rule out differential diagnoses (e.g., biliary obstruction, cholangitis ).
- RUQ ultrasound with Doppler: (preferred): may show findings of fatty liver disease; (e.g., steatosis, hepatomegaly, and periportal edema) and/or cirrhosis 
- CT or MRI abdomen: may show findings of fatty liver disease (e.g., decreased liver attenuation, heterogeneous steatosis) and/or cirrhosis 
Additional diagnostic workup 
Obtain additional studies to exclude differential diagnoses and identify comorbidities; workup should be guided by clinical suspicion and may include the following:
- Autoimmune hepatitis: e.g., ANAs, , IgG levels
- Metabolic liver disease: e.g., serum ceruloplasmin, alpha-1 antitrypsin levels
- : e.g., medication review, urine toxicology, serum acetaminophen levels
- (NAFLD): e.g., alcoholic liver disease/nonalcoholic fatty liver disease index (ANI) to help differentiate alcoholic liver disease from NAFLD 
Liver biopsy 
- Indications: (not routinely recommended)
- Technique: Transjugular liver biopsy is preferred. 
- Findings: signs of alcoholic steatohepatitis and/or cirrhosis (see “Pathology” in “Alcoholic liver disease” for details).
Histopathological findings of alcoholic steatohepatitis may be indistinguishable from findings of ; the ANI can help differentiate between the two.
Prognostic scoring systems
|Noninvasive prognostic scoring systems in alcoholic hepatitis |
|Maddrey discriminant function (MDF) || |
|Model for End-stage Liver Disease (MELD) score |
|Lille model for alcoholic hepatitis |
- Another alcoholic liver disease (e.g., )
- Infection (e.g., )
- Biliary obstruction (e.g., stones, tumors, strictures)
- Drug-induced liver injury (e.g., due to the use of acetaminophen, cocaine, prescription pharmaceuticals)
- hepatitis A, hepatitis B, hepatitis C) (e.g.,
- Metabolic liver disease
- Ischemic hepatitis (e.g., due to hypotension, shock, massive blood loss, or cocaine or other vasoconstrictor use)
The differential diagnoses listed here are not exhaustive.
These recommendations are consistent with the 2019 AASLD and 2018 ACG clinical guidelines. 
- Advise immediate alcohol cessation and monitor for .
- Ensure adequate calorie and micronutrient intake.
- In patients with severe disease, consider glucocorticoid therapy and referral for early liver transplantation.
- Prevent and manage comorbidities and complications, including:
Consider ICU admission in any of the following situations:
- Extrahepatic organ failure
- Stage III or IV
- Respiratory failure or the need for ventilatory support
- Hemodynamic instability or
Alcohol cessation 
- Advise patients to abstain completely from alcohol; no amount of alcohol consumption is considered safe. 
- Assess for alcohol withdrawal syndrome. 
- Refer to an addiction medicine specialist for .
Alcohol cessation may lead to . 
Nutritional support 
- Enteral route is preferred.
- Ensure a caloric intake of 35–40 kcal/kg/day.
- Daily protein requirement: 1.2–1.5 g/kg
- Replete zinc and other trace elements.
- Replete thiamine and other B-complex vitamins.
- IV albumin is preferred over IV crystalloids for volume replacement.
Pharmacological therapy 
Evidence regarding the benefit of pharmacological treatment for alcoholic hepatitis is mixed.
The AASLD and ACG recommend glucocorticoid use in selected cases.
- Indication: Severe alcoholic hepatitis (i.e., MDF score ≥ 32 or MELD score > 20) and no contraindications 
- Preferred agents
Monitoring: Calculate the Lille score to assess response after 4–7 days of treatment with glucocorticoids. 
- Lille score ≥ 0.45: Patient is not responding; stop glucocorticoids and consider further treatment options (e.g., supportive care, palliative care, early liver transplantation).
- Lille score < 0.45: Patient is responding; continue glucocorticoids to complete 28 days of treatment, followed by 2–4 weeks of taper.
Patients who do not respond within the first week of glucocorticoid treatment are unlikely to derive benefit from continued treatment. 
Other medications 
Other medications may be considered for patients with severe alcoholic hepatitis.
- N-Acetylcysteine 
Early liver transplantation 
- Definition: liver transplantation without 6 months of abstinence from alcohol
- Consider in patients with the following:
- No response to supportive or pharmacological management
- Favorable psychosocial profiles
Acute management checklist
- Check indications for ICU level of care.
- Obtain initial studies (e.g., CBC, liver chemistries, BMP, INR, RUQ ultrasound).
- Obtain an infectious disease workup (e.g., blood cultures).
- Consider referral for liver biopsy if confounding factors (e.g., differential diagnoses of alcoholic hepatitis, uncertain alcohol use) are present.
- Assess disease severity using the Maddrey discriminant function and MELD score.
- Start glucocorticoid therapy in patients with severe disease and no contraindications.
- Monitor response to glucocorticoids using the Lille score.
- Monitor and manage patients for alcohol withdrawal syndrome (e.g., using the score).
- Encourage abstinence from alcohol and provide
- Consider referral for liver transplant in patients with severe disease who are unresponsive to supportive management and pharmacological treatment.