Alcoholic Hepatitis

A meta-analysis of nutritional supplementation for management of hospitalized alcoholic hepatitis

BACKGROUND

Alcoholic liver disease (ALD) is associated with a high risk of morbidity and mortality. Malnutrition accompanies this condition and may be both a consequence of and contributor to the pathology. Many trials have investigated the benefits of providing supplemental nutrition in the management of patients with ALD. The present study is a meta-analysis of the available evidence.

METHOD

A meta-analysis of randomized controlled studies comparing nutritional supplementation plus a normal hospital diet versus diet alone.

RESULTS

Seven randomized controlled studies including 262 patients with ALD were identified. Pooled analysis revealed no statistical difference in mortality between groups given special nutritional therapy versus a normal balanced diet (OR 0.80 [95% CI 0.42 to 1.52]). In addition, nutrition did not significantly improve ascites (OR 1.29 [95% CI 0.52 to 3.20]) or any biochemical parameters. However, encephalopathy showed a significant improvement or resolution (OR 0.24 [95% CI 0.06 to 0.93]).

CONCLUSION

Nutritional supplementation provided no mortality benefit in patients with ALD, and neither ascites nor biochemical parameters significantly improved. However, encephalopathy was significantly ameliorated and, therefore, nutritional supplementation should be encouraged in that setting.

Acute alcoholic hepatitis

Acute alcoholic hepatitis (AAH) is a frequent inflammatory liver disease with high short-term mortality rate. In this review, relationships between alcohol abuse and the epidemiology and the outcomes of AAH are discussed, as well as AAH pathogenesis. The role of endotoxins, tumor necrosis factor alpha, fibroblasts, and immune response to altered hepatocyte proteins is discussed. The need of a careful prognosis, supported by the use of Maddrey score, by the model for end-stage liver disease [Mayo end-stage liver disease (MELD)] score or by the Glasgow alcoholic hepatitis score, is outlined, as the use of the most effective drugs (glucocorticoids and anti-tumor necrosis factor alpha infliximab) is recommended only in severe AAH cases. The problems of liver transplant in severe AAH, and the need of a 6-month alcohol abstinence before transplant, are discussed, as well as the need of a careful psychologic assessment before the transplant.

Alcoholic Hepatitis

Alcoholic hepatitis is a common clinical problem confronting gastroenterologists and hepatologists alike. The fundamental issue regarding treatment of this disease is its recognition on the part of the physician. Chronic alcohol abuse, fever, leukocytosis, jaundice, and encephalopathy are key symptoms and signs that should prompt consideration of this diagnosis. Nutrition and abstinence from alcohol are the cornerstones of therapy. In addition, management of seriously ill, hospitalized patients should include prophylaxis for withdrawal and delirium tremens. Alcoholic hepatitis (AH) induces a profound catabolic state, resulting in net negative nitrogen balance. In part, because of malnutrition, AH carries a considerably high mortality rate. Therefore, nutrition remains a key aspect of therapy. In the absence of encephalopathy and in the presence of a functioning gastrointestinal tract, oral intake or nasogastric feedings should be given. If the gastrointestinal tract cannot be used (ie, because of paralytic ileus), then total parenteral nutrition is absolutely essential for recovery. A select subset of patients, based on multiple clinical trials and several meta-analyses, can be treated with corticosteroids provided that the patient does not have active gastrointestinal bleeding and does not have an active infection. The subset of patients with AH who should receive corticosteroids is based on calculation of a modified Maddrey discriminant function, which incorporates the patient's prothrombin time and total serum bilirubin as variables in this equation. Generally, a 4-week course of prednisone or prednisolone is administered. d-penicillamine, colchicine, anabolic steroids, propylthiouracil, and antioxidants have not been shown to be effective in AH and cannot be recommended. After acute illness, patients should be discharged to an inpatient alcohol rehabilitation unit to ensure continued abstinence.