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Alcoholic Hepatitis B Alcoholic Liver Disease – Strategies for Seamless Care or An Clinical Approach to the Jaundiced Alcoholic Patient Liver Disease for the General Physician Royal College of Physicians July 2017 Dr Ewan Forrest Glasgow Royal Infirmary Increasing Burden of Alcoholic Liver Disease • >60% increase in discharges with alcoholic liver disease 2000/1 to 2009/10. • 222% increase in alcohol-related deaths 1980 to 2010. The start of another medical receiving ward round..... • 35 year old woman – history of alcohol excess; flu-like symptoms for 5 days – increasingly unwell; yellow eyes • Bilirubin 126; AST 3241; ALT 1194; ALP 234; PTr 3.9 • Jaundiced; no ascites evident • What is this likely to be? A. Alcoholic Hepatitis B. Acute Liver Injury C. Portal Vein Thrombosis D. Decompensated Alcoholic Cirrhosis E. Ascending Cholangitis Biochemical Patterns of Alcoholic Liver Disease De Ritis Ratio Decision Limit Condition <1.0 1.0 to <1.5 1.5 to <2.0 ≥ 2.0 Women (up to 1.7) Healthy Children Neonate Men (up to 1.3) Acute Viral Hepatitis Resolving Worsening Fulminant Alcoholic Liver Disease Resolving Alcohol Abuse Acute Hepatitis Chronic Liver Disease Stable Fibrosis risk Other Causes Muscle Disease Chronic Resolving Acute • Raised AST : ALT ratio (De Ritis Ratio) • AST not >500 (ALT usually <300) The Jaundiced Alcoholic: Scenario 1 • Acute Liver Injury – In context of either no background fibrotic liver disease or established cirrhosis – Atypical biochemistry; clinical context – Possible Causes • Drug induced: even ‘therapeutic’ paracetamol • Acute viral infection (HAV; HBV; HEV) • Ischaemic/ Hypoxic hepatitis • Co-incident primary liver disease: AIH Another ward round in an alternate universe..... • 35 year old woman – >80g alcohol per day; abdominal and ankle swelling – increasingly unwell for 6 months; yellow eyes for 4 months • Bilirubin 105; AST 93; ALT 32; ALP 234; PT 22 seconds (PTr 1.9); Urea 6.5; WCC 3.4 • Jaundiced; drowsy; moderate abdominal distension; hepatic flap present. • What is this likely to be? A. Alcoholic Hepatitis B. Acute Liver Failure C. Acute Portal Vein Thrombosis D. Decompensated Alcoholic Cirrhosis E. Ascending Cholangitis The Jaundiced Alcoholic: Scenario 2 • Chronic Decompensation of Chronic Disease – In context of established cirrhosis – Typical biochemistry; SIRS not florid – Clinical Context • Progressive deterioration over weeks/ months • Jaundice evident >2 months • Ascites and encephalopathy often predominant – Represents progressive disease with continued drinking but may herald development of hepatoma In the next bed, just arrived..... • 35 year old woman – >80g alcohol per day; flu-like symptoms for 5 days – increasingly unwell; yellow eyes for 2 weeks • Bilirubin 326; AST 241; ALT 94; ALP 234; PT 27seconds (PTr 2.4); Urea 6.5; WCC 17.4 • Jaundiced; pyrexial; drowsy; abdominal distension • Abdominal US showed large ascites and hepato-splenomegaly. • What should we do next? A. Percutaneous liver biopsy B. MRCP C. Transjugular liver biopsy D. CT Head E. Diagnostic Ascitic Aspiration Sepsis in Alcoholic Liver Disease • Ascitic Fluid Analysis – SBP diagnosed in 20% cirrhotics admitted to hospital, and 2-3% attending for outpatient paracentesis – >250 neutrophils/cm3 (>500 WBC/ cm3) and suggest spontaneous bacterial peritonitis (SBP) – Samples to be sent in ‘blood’ culture bottles – Early antibiotics (see local guidelines) and Albumin (20% HAS: 1.5g/kg Day 1; 1g/kg Day 3 for high risk patients: Bilirubin >68 and/or Urea>11) The Jaundiced Alcoholic: Scenario 3 • Acute Decompensation of Chronic Disease – Precipitant: often GI bleeding/ Sepsis/ Portal Vein Thrombosis – Typical biochemistry; SIRS usually evident – Clinical Context • Can be difficult to differentiate from Alcoholic Hepatitis (and may co-exist) – Full sepsis screen: blood cultures; urinalysis and culture; diagnostic ascitic tap; CXR – Low threshold for antibiotics (but be wary of gentamicin) BSG/BASL Clinical Bundle for Decompensated Liver Disease: the First 24 hours Stuart McPherson et al. Frontline Gastroenterology Curiously an hour later there arrives...... • 35 year old woman • Bilirubin 326; AST 241; ALT 94; ALP 234; PT 27seconds (PTr 2.4); Urea 6.5; WCC 17.4 • Jaundiced; pyrexial; drowsy; moderate abdominal distension • Abdominal US showed moderate ascites and hepato- splenomegaly. • Sepsis screen negative • What is this likely to be? A. Alcoholic Hepatitis B. Acute Liver Failure C. Portal Vein Thrombosis D. Decompensated Alcoholic Cirrhosis E. Ascending Cholangitis The Jaundiced Alcoholic: Scenario 4 • ‘Clinically relevant’ Alcoholic Hepatitis – Essential Features • excess alcohol within 8 weeks • < 2 month onset of Bilirubin > 80mol/l • Exclusion/ treatment of sepsis • AST < 500 (AST: ALT ratio >1.5) – Characteristic Features • hepatomegaly fever leucocytosis hepatic bruit NIAAA 2016: Probable Alcoholic Hepatitis Inclusion Criteria •Onset of jaundice within prior 8 weeks •Ongoing consumption of > 40 (female) or 60 (males) g alcohol/day for ≥6 months with <60 days of abstinence before the onset of jaundice •Aspartate aminotransferase > 50, aspartate aminotransferase/alanine aminotransferase > 1.5, and both values < 400 IU/L •Serum bilirubin (total) > 3.0 mg/dL (50µmol/l) •Liver biopsy confirmation in patients with confounding factors Back to our patient...... • 35 year old woman • Bilirubin 326; AST 241; ALT 94; ALP 234; PT 27seconds (PTr 2.4); Urea 6.5; WCC 17.4 • Jaundiced; pyrexial; drowsy; moderate abdominal distension • Abdominal US showed moderate ascites and hepato- splenomegaly. • What is her short-term (28 day)prognosis? A. Excellent (>95% survival) B. Reasonable (~80% survival) C. Moderate (~60% survival) D. Poor (~50% survival) E. Terrible (<40% survival) We Need to Talk About Maddrey....... • DF: the usual means of identifying ‘severe’ alcoholic hepatitis DF = 4.6 (PTPATIENT – PTCONTROL) + Serum Bilirubin (mol/l) / 17 • Kulkarni et al, 2004 – 89 patients • BUT – C-statistic: 0.666 – Concerns regarding accuracy (50%) – Wide variation in the measurement of prothrombin time The Glasgow Alcoholic Hepatitis Score 100 Score Given 1 2 3 80 Age < 50 50 - 9 WCC (10 /l) < 15 15 - 60 Urea (mmol/l) < 5 5 - DF DF PT ratioGAHS/ INR < 1.5 1.5 – 2.0 > 2.0 Sensitivity 40 GAHS Bilirubin (mol/l) < 125 125 - 250 > 250 AUC: GAHS = 0.783 20 (0.736 – 0.825) DF = 0.721 Day 28 Outcome Day 84 Outcome (0.671 – 0.767) (Accuracy) (Accuracy) 0 (p=0.014)Day 1 GAHS</≥9 81% 75% Data 0 20 40 60 80 100 DF</≥32 49% 53% 100-Specificity Day 6-9 GAHS</≥9 81% 78% AUC: Data GAHS = 0.783 (0.736 – 0.825) DF</≥32 52% 57% DF = 0.721 (0.671 – 0.767) (p=0.014) Alternatives to GAHS: – MELD=3.8 x loge(bilirubin, mg/dl)+ 11.2 x loge(INR)+ 9.6 x loge(creatinine,mg/dl) – ABIC=(age*0.1)+(bilirubin*0.08)+(creatinine*0.3)+(INR*0.8) <6.71 100% survival 6.71 – 9.0 70% survival >9.0 22% survival – Lille Score: R = 3.19 - (0.101*age in years) + (0.147*albumin day 0 in g/L) + (0.0165*evolution in bilirubin level in M) - (0.206*renal insufficiency)#- (0.0065*bilirubin day 0 in M) - (0.0096*INR) # creatinine>115M Score = EXP(-R) / [1+EXP(-R)] Back to our patient...... • 35 year old woman • Bilirubin 326; AST 241; ALT 94; ALP 234; PT 27seconds (PTr 2.4); Urea 6.5; WCC 17.4; Alb 26 • Jaundiced; pyrexial; drowsy; moderate abdominal distension • US showed moderate ascites and hepato-splenomegaly. • Sepsis screen negative • What treatment should be considered? A. Terlipressin and Albumin infusions B. Pentoxifylline orally C. Prednisolone orally D. Rifaximin E. Broad spectrum antibiotics STeroids Or Pentoxifylline for Alcoholic Hepatitis • Pentoxifylline 400mg tds; Prednisolone 40mg: each for 4 weeks • Primary End-point: 28 Day mortality Pentoxifylline No Yes Total 16.7% 19.4% 18.0% No (45/269) (50/258) (95/527) Prednisolone 14.3% 13.5% 13.9% Yes (38/266) (35/260) (73/526) 15.5% 16.4% 16.0% Total (83/535) (85/518) (168/1053) STOPAH: Mortality Prednisolone vs No Prednislone Pentoxifylline vs No Pentoxifylline OR = 0.72 (0.52 - 1.01) p = 0.056 OR = 1.07 (0.77 - 1.49) p = 0.686 OR = 1.02 (0.77 - 1.35) p = 0.875 OR = 0.97 (0.73 - 1.28) p = 0.807 OR = 1.01 (0.76 - 1.35) p = 0.937 OR = 0.99 (0.74 - 1.33) p = 0.972 Determinants of 28 Day Outcome Multivariate and Meta- Analysis Multivariate Analysis Variable Odds ratio (95% CI) p-value Prednisolone vs no prednisolone 0.609 (0.409 – 0.090) 0.015 Prothrombin ratio 1.381 (1.129 – 1.691) 0.002 Bilirubin 1.002 (1.001 – 1.003) 0.003 Age 1.050 (1.029 – 1.071) <0.001 White Blood Cells 1.030 (1.002 – 1.060) 0.037 Urea 1.065 (1.015 – 1.118) 0.037 Creatinine 1.564 (1.048 – 2.332) 0.028 Hepatic Encephalopathy 3.073 (2.050 – 4.605) <0.001 Risks of Prednisolone in Alcoholic Hepatitis: Infection Placebo/ Pred/ Placebo/ Pred/ Total Placebo Placebo PTX PTX (n=1092) (n=272) (n=274) (n=273) (n=273) Infections and infestations 27 (20%) 44 (24%) 16 (11%) 30 (19%) 117 (19%) Lung infection 11 (8%) 20 (11%) 6 (4%) 18 (11%) 55 (9%) • Infection developed in 13% of those who received prednisolone (cf 7%; p=0.002) • Vergis et al, 2017: for patients who present with infection – If not receiving prednisolone, continuation of antibiotics does not impact upon mortality – If receiving prednisolone concurrent antibiotic therapy significantly reduces mortality Corticosteroid Responsiveness: baseline disease severity *p<0.05 cf no treatment #p<0.005 cf no treatment Corticosteroid ‘Responsiveness’: Day 7 Progress • Mathurin et al, 2003 • Louvet et al, 2007 – 238 patients: DF32, – 320 patients: DF 32, biopsy-proven AH. biopsy-proven; 118 in validation set. – ECBL response. – ‘Lille model’ Intensive Enteral Nutrition in Alcoholic Hepatitis • Moreno et al 2016 – ‘Conventional nutrition’ or intensive EN: 14 days NG tube – 48.5% premature NG tube removal: 3 cases of aspiration – No increased risk of upper GI bleeding – 6 month mortality: 44.4% with EN; 52.1% without (p=0.406) – Improved survival if ≥1692kcal/day or ≥21.5kcal/kg/day irrespective of treatment group GAHS EASL Guidelines 2012 ? 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