Gastrointestinal & Hepatic · Topic 10 of 26

Alcohol-Associated Hepatitis

Hepatic · alcohol-associated liver disease

Alcohol-Associated Hepatitis

New jaundice in a heavy drinker: MELD above 20 is severe — give prednisolone 40 mg if there is no infection, and stop it when Lille exceeds 0.45.

Key numbers

MELD > 20 defines severe diseaseMELD > 20

Prednisolone 40 mg daily for 28 days40 mg/day × 28 days

Stop steroids if Lille score > 0.45Lille > 0.45

01 · Defined byMELD > 20 defines severe disease

Severity is stratified with MELD: MELD > 20 = severe alcohol-associated hepatitis with high short-term mortality — hospitalize and consider corticosteroids; MELD ≤ 20 = moderate.

02 · GivePrednisolone 40 mg daily for 28 days

For severe disease without contraindications give prednisolone 40 mg orally daily for 28 days (IV methylprednisolone 32 mg/day if unable to take oral drugs); no evidence favors a rapid or slow taper afterward.

03 · WatchStop steroids if Lille score > 0.45

Calculate the Lille score on day 7 (or day 4) of corticosteroids; a score above 0.45 means nonresponse — stop steroids and consider early transplant evaluation or a clinical trial.

Presentation

What you'll see

Fever, jaundice, tender hepatomegaly, leukocytosisTypical presentation: fever, jaundice, right upper quadrant pain, tender hepatomegaly and neutrophilic leukocytosis; SIRS can occur without infection, and about 40% deteriorate after admission.

Diagnosis & monitoring

Work-up

New jaundice, bilirubin > 3, AST:ALT > 1.5 must knowProbable alcohol-associated hepatitis (NIAAA): jaundice within the past 8 weeks, bilirubin > 3 mg/dL, AST > 50 IU/L with AST:ALT > 1.5 and both < 400 IU/L, in ongoing heavy drinking; biopsy is not required.

Do right now

In this order

First moves

Screen for infection before starting steroids

→

MELD > 20 defines severe diseaseMELD > 20

→

Prednisolone 40 mg daily for 28 days40 mg/day × 28 days

→

Stop steroids if Lille score > 0.45Lille > 0.45

Why each step

Screen for infection before starting steroidsInfection is common at presentation and mimics AH: obtain blood and urine cultures, chest radiograph, diagnostic paracentesis if ascites is present, and Doppler ultrasound to exclude other causes of jaundice before corticosteroids.

MELD > 20 defines severe diseaseSeverity is stratified with MELD: MELD > 20 = severe alcohol-associated hepatitis with high short-term mortality — hospitalize and consider corticosteroids; MELD ≤ 20 = moderate.

Prednisolone 40 mg daily for 28 daysFor severe disease without contraindications give prednisolone 40 mg orally daily for 28 days (IV methylprednisolone 32 mg/day if unable to take oral drugs); no evidence favors a rapid or slow taper afterward.

Stop steroids if Lille score > 0.45Calculate the Lille score on day 7 (or day 4) of corticosteroids; a score above 0.45 means nonresponse — stop steroids and consider early transplant evaluation or a clinical trial.

Management

Orders

Abstinence is what determines long-term survival must knowSustained abstinence is the single most important determinant of long-term survival after alcohol-associated hepatitis; treat the alcohol use disorder alongside the liver disease, ideally with an addiction specialist.

Add IV N-acetylcysteine to corticosteroidsACG recommends IV N-acetylcysteine as an adjuvant to corticosteroids in severe alcohol-associated hepatitis.

Feed 35 kcal/kg and 1.2–1.5 g/kg proteinTarget 35 kcal/kg/day and 1.2–1.5 g/kg/day protein, preferably oral or enteral; give nutritional support when intake falls below 21 kcal/kg/day, and replace thiamine, vitamin B12 and zinc.

Early transplant for selected nonrespondersConsider early liver transplant for highly selected patients with severe AH who do not respond to medical therapy; selection follows institutional psychosocial criteria rather than a fixed 6-month abstinence rule.

Baclofen for AUD; never disulfiramIn compensated alcohol-associated liver disease, baclofen is recommended for alcohol use disorder and acamprosate or naltrexone are options; disulfiram is contraindicated in any liver disease because it is hepatotoxic.

Red flags & don'ts

Avoid harm

Steroids barred by infection, bleeding, renal failure avoidContraindications to corticosteroids: active infection, untreated hepatitis B, uncontrolled diabetes, GI bleeding and severe renal failure; steroids can start once infection, bleeding or renal failure is controlled.

Do not use pentoxifylline avoidPentoxifylline is not recommended for severe alcohol-associated hepatitis: it showed no survival benefit in STOPAH and does not rescue steroid nonresponders.

The rules

Know these

No routine prophylactic antibioticsDo not give universal prophylactic antibiotics to hospitalized patients with severe alcohol-associated hepatitis; treat documented infection.

More detail

Reference

Show 5 reference facts

The NIAAA drinking criterion is > 40 g/day (women) or > 60 g/day (men) for 6 months or more, with less than 60 days of abstinence before jaundice began.

ACG 2024: corticosteroid benefit is greatest at MELD 25–39; weigh risks carefully above MELD 50. Patients whose bilirubin falls quickly by day 7 ('fast fallers') did not benefit from steroids.

Aminotransferases are only moderately raised (usually < 300 IU/L) with AST:ALT ≥ 2 — ALT is low from pyridoxal phosphate deficiency — and GGT is often elevated.

Patients with severe AH who do not respond to corticosteroids, are ineligible for early transplant and have 4 or more organ failures are appropriate for palliative care.

Prednisolone increases infection risk after treatment; TNF-α inhibitors raised infection deaths in trials and are not used.

Pearl

Score it, screen it, steroid it, then Lille it: MELD > 20, no infection, prednisolone 40 mg, and stop at day 7 if Lille > 0.45.

Sources · Jophlin LL et al. ACG Clinical Guideline: Alcohol-Associated Liver Disease. Am J Gastroenterol 2024;119:30–54 · Crabb DW et al. Diagnosis and Treatment of Alcohol-Associated Liver Diseases: 2019 Practice Guidance From the AASLD. Hepatology 2020;71:306–333 · Merck Manual Professional — Alcohol-Related Liver Disease · Crabb DW et al. Standard Definitions and Common Data Elements for Clinical Trials in Patients With Alcoholic Hepatitis: Recommendation From the NIAAA Alcoholic Hepatitis Consortia. Gastroenterology 2016;150:785–790 · Starter sheet built from the verified AGACNP fact map (facts reviewed 2026-10-15).