Case Presentation: A 50-year-old woman presented with two weeks of progressively worsening abdominal pain and distention. The abdominal pain was accompanied by yellowing of her eyes and periods of confusion. She reported consuming 4 shots of vodka daily for greater than 10 years. Vital signs were normal. The patient was grossly jaundiced and exhibited scleral icterus. Her abdomen was distended with a fluid wave. She was alert and oriented; she exhibited asterixis. Labs revealed Na 123, Cr 2.0, total bilirubin 17, AST 250, ALT 80, PT 24, INR 2.0. Hepatitis A, B, and C panels were non-reactive. CT of the abdomen demonstrated severe hepatomegaly and steatosis with perihepatic fluid and ascites. The patient received intravenous methylprednisolone for severe alcoholic hepatitis, but laboratory values did not improve, and she became increasingly encephalopathic. She was subsequently transferred to a liver transplant center.

Discussion: Alcoholic hepatitis is a condition commonly encountered by the internist. Patients typically have a history of alcohol abuse, and present with jaundice and right upper quadrant pain. Laboratory testing reveals elevated transaminases, with an AST generally less than 300, and an AST to ALT ratio greater than two. The severity of alcoholic hepatitis is graded by the discriminant function score, which is calculated from the patient’s total bilirubin and prothrombin time. A score greater than 32 is considered severe and is treated with glucocorticoids. Failure to improve after steroid administration carries a 6-month mortality greater than 70%.
Liver transplantation is a controversial but life-saving measure for patients with severe alcoholic hepatitis who do not respond to medical therapy. This treatment poses an ethical dilemma as donor organs are a scarce resource and these patients have not yet demonstrated an ability to abstain from alcohol. However, transplantation in carefully selected patients results in survival and recidivism rates similar to patients with alcoholic cirrhosis who abstain from alcohol for 6 months prior to surgery.

Conclusions: Glucocorticoids remain the mainstay of treatment for patients with severe alcoholic hepatitis; however, failure to respond to steroid therapy carries a poor prognosis. Liver transplantation serves as a controversial but effective therapy for patients with refractory alcoholic hepatitis.