Clinical Commander

All dossiers
hep.alcoholic-hepatitis.core.v1

Severe Alcoholic Hepatitis

hepatologyacuteadultacuteinpatient
Start encounter →Print handoutPRODUCTION

Fresh hep.* prefix dossier; manifest is batch23 scaffold (no AH-specific workup adapter; uses sbp_workup + hepatic_encephalopathy + hepatorenal_syndrome). Severity gates: Maddrey DF >=32 (PMID 352788) OR MELD >=21 (Crabb 2020 PMID 31314133); both embedded in regimen rationale since no calc.maddrey/calc.lille registry entries exist. STOPAH 2015 (PMID 25901427) - prednisolone trend; pentoxifylline NEGATIVE - explicitly NOT recommended. Lille day-7 score (PMID 17518367) drives steroid continuation vs early transplant decision; non-responders go to Mathurin 2011 (PMID 22070476) early TX pathway. PREDNISOLONE not prednisone (no hepatic conversion needed in failing liver). NAC adjunct per Nguyen-Khac 2011 (rationale only; not separately PMID-anchored here). Sibling differentiation vs cirrhosis + ALF explicit.

Entry points (4)

  • symptom
    New jaundice (within 8 weeks) + active heavy alcohol use (AASLD ALD 2019)
    new_jaundice_with_alcohol
  • symptom
    Fever, anorexia, tender hepatomegaly in heavy drinker (AASLD ALD 2019)
    fever_anorexia_hepatomegaly
  • lab_abnormality
    AST/ALT >1.5:1 with both <500 U/L + bilirubin >3 mg/dL in active drinker (AASLD ALD 2019)
    ast_alt_ratio_>1_5_alcohol
  • history
    Heavy alcohol use (women >3 drinks/day or 7/wk; men >4 drinks/day or 14/wk) for >=6 months with active use within 60 days (AASLD ALD 2019)
    heavy_alcohol_use_>3_drinks_day_women_>4_men

Required inputs (19)

  • agerequired
    demographic • used at CONTEXT
    Lille model component; transplant candidacy (Mathurin 2011)
  • sexrequired
    demographic • used at CONTEXT
    Women metabolize alcohol less efficiently; lower threshold for AH (AASLD ALD 2019)
  • temperaturerequired
    vital • used at CONTEXT
    Fever common in AH; rule out concurrent SBP/sepsis (AASLD ALD 2019)
  • sbprequired
    vital • used at CONTEXT
    Hypotension precipitates HRS-AKI; sepsis screen (AASLD ALD 2019)
  • hrrequired
    vital • used at CONTEXT
    Hyperdynamic circulation; SIRS / infection screen (AASLD ALD 2019)
  • total_bilirubinrequired
    lab • used at INITIAL_WORKUP
    Maddrey DF component + Lille day-7 component + MELD component (Maddrey 1978; Louvet 2007)
  • inrrequired
    lab • used at INITIAL_WORKUP
    MELD component; prothrombin time drives Maddrey DF (Maddrey 1978)
  • ptrequired
    lab • used at INITIAL_WORKUP
    Maddrey DF = 4.6 x (patient PT - control PT) + bilirubin mg/dL; DF >=32 = severe (Maddrey 1978)
  • creatininerequired
    lab • used at INITIAL_WORKUP
    MELD component; Lille model component; HRS-AKI screen (Louvet 2007)
  • sodiumrequired
    lab • used at INITIAL_WORKUP
    MELD-Na component; hyponatremia portends poor prognosis (AASLD ALD 2019)
  • albuminrequired
    lab • used at INITIAL_WORKUP
    Lille model component; nutritional status (Louvet 2007; Crabb 2020)
  • ast_altrequired
    lab • used at INITIAL_WORKUP
    AST/ALT >1.5:1 with both <400 typical of AH (AASLD ALD 2019)
  • plateletsrequired
    lab • used at INITIAL_WORKUP
    Thrombocytopenia common; cirrhosis baseline (AASLD ALD 2019)
  • wbcrequired
    lab • used at INITIAL_WORKUP
    Leukocytosis common but rule out infection (AASLD ALD 2019)
  • liver_us_dopplerrequired
    imaging • used at INITIAL_WORKUP
    Rule out biliary obstruction, Budd-Chiari, HCC; assess cirrhosis (AASLD ALD 2019)
  • alcohol_pattern_quantity_durationrequired
    history • used at CONTEXT
    AUDIT score; relapse risk for transplant candidacy (AASLD ALD 2019)
  • medication_supplement_reviewrequired
    history • used at CONTEXT
    Rule out DILI / APAP co-toxicity (LiverTox); HDS (AASLD ALD 2019)
  • acetaminophen_level
    lab • used at INITIAL_WORKUP
    Rule out co-ingestion - APAP toxicity potentiated in alcohol users (Stravitz Lee 2019)
  • viral_hepatitis_serologiesrequired
    lab • used at INITIAL_WORKUP
    HBsAg + anti-HCV + HCV RNA (co-infection common) (AASLD ALD 2019)

12-phase flow (12)

  1. 1FRAME
    Confirm severe AH scope: new jaundice + bili >3 + AST/ALT >1.5:1 + heavy alcohol within 60d + Maddrey DF >=32 OR MELD >=21 (AASLD ALD 2019)
    inputs: total_bilirubin, ast_alt
    advance: severe AH defined
  2. 2ENTRY
    Recognize jaundice + heavy alcohol use + cholestatic LFT pattern (AASLD ALD 2019)
    advance: one entry trigger present
  3. 3CONTEXT
    Alcohol pattern/quantity/duration (AUDIT), medication review (APAP, NSAIDs, herbal), prior decompensations, transplant candidacy factors (social support, abstinence period) (AASLD ALD 2019)
    inputs: age, sex, temperature, sbp, hr, alcohol_pattern_quantity_duration, medication_supplement_review
    advance: context captured
  4. 4RED_FLAGS
    Concurrent SBP (diagnostic para mandatory), HRS-AKI, variceal bleed, HE grade 3-4, severe sepsis - precludes or delays steroids (AASLD ALD 2019; Crabb 2020)
    inputs: sbp, creatinine
    actions: sbp_workup, hepatic_encephalopathy, hepatorenal_syndrome
    advance: red flags ruled out or treated
  5. 5INITIAL_WORKUP
    CBC, LFT (bilirubin/AST/ALT/ALP/GGT), BMP (Cr/Na), albumin, INR/PT, lipase, viral hepatitis serologies, ANA/SMA/IgG (rule out AIH), ferritin/iron sat, ceruloplasmin <40yo, blood cultures, urinalysis, RUQ ultrasound (AASLD ALD 2019)
    inputs: total_bilirubin, inr, pt, creatinine, sodium, albumin, ast_alt, platelets, wbc, liver_us_doppler, viral_hepatitis_serologies
    actions: panel.lft, panel.cbc, panel.renal, panel.coag
    advance: core labs + US obtained
  6. 6BRANCHING_WORKUP
    Diagnostic paracentesis MANDATORY on every admission with ascites; transjugular liver biopsy ONLY if diagnosis uncertain (5% non-AH on biopsy); MRCP if cholestatic and US equivocal (AASLD ALD 2019)
    actions: sbp_workup
    advance: concurrent infection excluded; diagnosis confirmed
  7. 7DIFFERENTIAL
    Distinguish from DILI (especially APAP, herbal), AIH flare, viral hepatitis flare, ischemic hepatitis, cholangitis, Budd-Chiari; biopsy reserved for atypical presentations (AASLD ALD 2019)
    advance: AH confirmed or alternative dx assigned
  8. 8RISK_STRATIFICATION
    Maddrey DF = 4.6*(PT-control PT) + bilirubin (DF >=32 = severe); MELD >=21 = severe alternative; ABIC, GAHS scores; STOPAH eligibility check (Maddrey 1978; Forrest 2007; Dominguez 2008)
    inputs: total_bilirubin, pt, creatinine, inr, sodium, albumin
    advance: severity grade assigned
  9. 9TREATMENT
    Alcohol cessation + nutrition (1.5 g/kg protein, late evening snack, NG feeding if oral intake <21.5 kcal/kg); prednisolone 40 mg PO daily x 28d for DF >=32 OR MELD >=21 (Crabb 2020 + STOPAH); add NAC IV (Nguyen-Khac 2011 - reduced HRS); pentoxifylline NOT recommended; rifaximin/lactulose for HE; ceftriaxone+albumin for SBP; terlipressin+albumin for HRS-AKI; refer for early liver transplant per Mathurin 2011 if Lille >=0.45 at day 7 (AASLD ALD 2019; Crabb 2020)
    inputs: total_bilirubin, creatinine
    advance: steroids started (if no contraindication) + transplant referral if applicable
  10. 10DISPOSITION
    ICU for HE 3-4 / shock / variceal bleed; floor for severe AH on steroids; outpatient hepatology only if mild AH (DF <32 + MELD <20) (AASLD ALD 2019)
    inputs: sbp
    advance: destination locked
  11. 11MONITORING
    Day 7 Lille score = exp(R)/(1+exp(R)) where R = 3.19 - 0.101*age + 0.147*albumin + 0.0165*(bili_day0 - bili_day7) - 0.206*Cr (1=yes,0=no for Cr >1.3) - 0.0065*bili_day0 - 0.0096*PT; Lille <0.45 = responder continue steroids; Lille >=0.45 = non-responder stop steroids + transplant evaluation (Louvet 2007)
    inputs: total_bilirubin, albumin, creatinine
    advance: day 7 response assessed
  12. 12FOLLOWUP
    Alcohol cessation programs (CBT, MAT - acamprosate/naltrexone/baclofen), nutrition, q1-3mo hepatology + addiction, vaccinations (HAV/HBV/influenza/pneumococcal), HCC surveillance if cirrhotic, transplant follow-up if listed (AASLD ALD 2019)
    advance: follow-up scheduled