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hep.alcoholic-hepatitis.core.v1PRODUCTION
hep.alcoholic-hepatitis.core.v1

Severe Alcoholic Hepatitis

hepatologyacuteadult
Hard-required inputs
0 / 18
Care setting:

Encounter flow

12/12 authored

Canonical 12-phase frame with authored status for this dossier.

Current phase

Frame

Detailed

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
2
Actions
0
Advance rule
Set
Advance when

severe AH defined

Patient inputs (19)

Lille model component; transplant candidacy (Mathurin 2011)

Women metabolize alcohol less efficiently; lower threshold for AH (AASLD ALD 2019)

Fever common in AH; rule out concurrent SBP/sepsis (AASLD ALD 2019)

Hypotension precipitates HRS-AKI; sepsis screen (AASLD ALD 2019)

Hyperdynamic circulation; SIRS / infection screen (AASLD ALD 2019)

AUDIT score; relapse risk for transplant candidacy (AASLD ALD 2019)

Rule out DILI / APAP co-toxicity (LiverTox); HDS (AASLD ALD 2019)

Maddrey DF component + Lille day-7 component + MELD component (Maddrey 1978; Louvet 2007)

MELD component; prothrombin time drives Maddrey DF (Maddrey 1978)

Maddrey DF = 4.6 x (patient PT - control PT) + bilirubin mg/dL; DF >=32 = severe (Maddrey 1978)

MELD component; Lille model component; HRS-AKI screen (Louvet 2007)

MELD-Na component; hyponatremia portends poor prognosis (AASLD ALD 2019)

Lille model component; nutritional status (Louvet 2007; Crabb 2020)

AST/ALT >1.5:1 with both <400 typical of AH (AASLD ALD 2019)

Thrombocytopenia common; cirrhosis baseline (AASLD ALD 2019)

Leukocytosis common but rule out infection (AASLD ALD 2019)

Rule out biliary obstruction, Budd-Chiari, HCC; assess cirrhosis (AASLD ALD 2019)

HBsAg + anti-HCV + HCV RNA (co-infection common) (AASLD ALD 2019)

Rule out co-ingestion - APAP toxicity potentiated in alcohol users (Stravitz Lee 2019)

* = hard-required. Engine cannot meaningfully run until these are filled.

Severity triggers (7)

7 need judgement
  • informationallife_threateninglille_>=0.45_day_7_non_responder
    Lille score >=0.45 at day 7 of prednisolone = non-responder; ~75% 6-month mortality on continued steroids (Louvet 2007)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationallife_threateninghrs_aki_in_ah
    HRS-AKI per ICA criteria in severe AH (Crabb 2020)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseveresevere_ah_maddrey_>=32
    Maddrey discriminant function >=32 ( 4.6 x (PT - control PT) + total bilirubin mg/dL ) (Maddrey 1978)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseveresevere_ah_meld_>=21
    MELD >=21 alternative severity threshold for AH (Crabb 2020)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalsevereinfection_on_prednisolone
    Bacterial or fungal infection diagnosed during prednisolone course (STOPAH 13% on pred vs 7% off)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseveresbp_in_ah
    Ascitic PMN >=250/mm^3 in AH (AASLD ALD 2019)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseveresevere_alcohol_withdrawal
    CIWA >=15 or seizure or DT in AH patient (AASLD ALD 2019)
    Trigger could not be auto-evaluated — needs clinician judgement.

Workflow calculators

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Recommended regimen

Severe alcoholic hepatitis - prednisolone with Lille day-7 gating + NAC adjunct + transplant for non-responders (AASLD ALD 2019; STOPAH 2015; Mathurin 2011)
axis: severe_ah_treatment_pathwaystep 1 - Step 1 - Initial assessment and supportive care (any severity)
Selected step "Step 1 - Initial assessment and supportive care (any severity)" — Any AH (mild or severe) at presentation
  • thiamine
    first line
    vitamin
    100-500 mg IV daily x 3-5d then 100 mg PO daily • IV/PO • daily
    triggers: AUD, malnutrition
    Wernicke prophylaxis BEFORE dextrose; standard in AUD (AASLD ALD 2019)
    rxcui 10454
  • folic_acid
    first line
    vitamin
    1 mg PO/IV daily • PO/IV • daily
    triggers: AUD
    Megaloblastic anemia prevention
    rxcui 4511
  • lorazepam
    rescue
    benzodiazepine
    1-2 mg IV/PO q4-6h prn CIWA >=10 • IV/PO • CIWA-triggered
    triggers: alcohol_withdrawal_CIWA_>=10
    AWS management; lorazepam preferred over oxazepam/diazepam in liver failure (less hepatic clearance dependence) but use minimum needed to avoid HE precipitant (AASLD ALD 2019)
    rxcui 6470

ed playbook — drug actions (6)

  1. 1. thiamine
    100-500 mg IV BEFORE dextrose • IV • daily x 3-5d
    trigger: Any AUD (AASLD ALD 2019)
    Wernicke prophylaxis
  2. 2. folic acid
    1 mg PO/IV daily • PO/IV • daily
    trigger: AUD (AASLD ALD 2019)
    Megaloblastic anemia prevention
  3. 3. lorazepam PRN AWS
    1-2 mg IV/PO q4-6h prn CIWA >=10 • IV/PO • CIWA-triggered
    trigger: Alcohol withdrawal (AASLD ALD 2019)
    Front-load AWS; minimum dose to avoid HE
  4. 4. ceftriaxone empiric SBP
    2 g IV daily • IV • daily
    trigger: Ascitic ANC >=250 OR concern for SBP (AASLD ALD 2019)
    Empiric SBP coverage
  5. 5. albumin if SBP
    1.5 g/kg day 1 • IV • one dose then second day 3
    trigger: SBP diagnosed (Sort 1999 NEJM)
    Reduces HRS-AKI and mortality
  6. 6. D10 IV
    D10W titrated to glucose >=70 mg/dL • IV • continuous
    trigger: Hypoglycemia (Crabb 2020)
    Hepatic gluconeogenesis failure

Auto-drafted A&P note

ed

Subjective

- Possible entry pathways: New jaundice (within 8 weeks) + active heavy alcohol use (AASLD ALD 2019); Fever, anorexia, tender hepatomegaly in heavy drinker (AASLD ALD 2019); AST/ALT >1.5:1 with both <500 U/L + bilirubin >3 mg/dL in active drinker (AASLD ALD 2019).

Objective

- No vitals, labs, or imaging entered for this encounter.

Assessment

**Severe Alcoholic Hepatitis** (hep.alcoholic-hepatitis.core.v1).
Phenotype framing: Distinguish from DILI (especially APAP, herbal), AIH flare, viral hepatitis flare, ischemic hepatitis, cholangitis, Budd-Chiari; biopsy reserved for atypical presentations (AASLD ALD 2019)
Scope: 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)

No severity triggers fired against current inputs.

Plan

Regimen axis: **Severe alcoholic hepatitis - prednisolone with Lille day-7 gating + NAC adjunct + transplant for non-responders (AASLD ALD 2019; STOPAH 2015; Mathurin 2011)** — step "Step 1 - Initial assessment and supportive care (any severity)".
1. thiamine 100-500 mg IV daily x 3-5d then 100 mg PO daily IV/PO daily (vitamin, first line) — Wernicke prophylaxis BEFORE dextrose; standard in AUD (AASLD ALD 2019)
2. folic_acid 1 mg PO/IV daily PO/IV daily (vitamin, first line) — Megaloblastic anemia prevention
3. lorazepam 1-2 mg IV/PO q4-6h prn CIWA >=10 IV/PO CIWA-triggered (benzodiazepine, rescue) — AWS management; lorazepam preferred over oxazepam/diazepam in liver failure (less hepatic clearance dependence) but use minimum needed to avoid HE precipitant (AASLD ALD 2019)

Setting playbook (ed) — Recognize severe AH (DF >=32 or MELD >=21), exclude infection, start thiamine BEFORE glucose, admit, hepatology consult (AASLD ALD 2019)
4. thiamine 100-500 mg IV BEFORE dextrose IV daily x 3-5d — Any AUD (AASLD ALD 2019) (Wernicke prophylaxis)
5. folic acid 1 mg PO/IV daily PO/IV daily — AUD (AASLD ALD 2019) (Megaloblastic anemia prevention)
6. lorazepam PRN AWS 1-2 mg IV/PO q4-6h prn CIWA >=10 IV/PO CIWA-triggered — Alcohol withdrawal (AASLD ALD 2019) (Front-load AWS; minimum dose to avoid HE)
7. ceftriaxone empiric SBP 2 g IV daily IV daily — Ascitic ANC >=250 OR concern for SBP (AASLD ALD 2019) (Empiric SBP coverage)
8. albumin if SBP 1.5 g/kg day 1 IV one dose then second day 3 — SBP diagnosed (Sort 1999 NEJM) (Reduces HRS-AKI and mortality)
9. D10 IV D10W titrated to glucose >=70 mg/dL IV continuous — Hypoglycemia (Crabb 2020) (Hepatic gluconeogenesis failure)

Non-pharmacologic actions:
- IV access x 2 + diet held until aspiration risk assessed (AASLD ALD 2019)
- CIWA scoring q4h (AASLD ALD 2019)
- Diagnostic paracentesis if ascites (Crabb 2020)
- Hepatology consult (AASLD ALD 2019)
- Addiction medicine / social work consult (AASLD ALD 2019)

AVOID / contraindication checks:
- Pentoxifylline_NOT_recommended_STOPAH_negative (Crabb 2020 + Thursz 2015 PMID 25901427)
- Prednisolone_contraindicated_active_uncontrolled_infection (Crabb 2020)
- Prednisolone_contraindicated_active_GI_bleed (Crabb 2020)
- Prednisolone_contraindicated_HRS_unresponsive_to_albumin_terlipressin (Crabb 2020)
- Prednisolone_contraindicated_severe_acute_pancreatitis (Crabb 2020)
- Use_PREDNISOLONE_not_prednisone_in_liver_failure_no_hepatic_conversion_needed (Crabb 2020)
- Benzodiazepine_minimize_HE_precipitant_lorazepam_only_PRN_AWS (AASLD ALD 2019)
- NSAID_avoid_HRS_GI_bleed_risk (AASLD ALD 2019)
- Aminoglycoside_avoid_HRS_risk (AASLD ALD 2019)
- Acetaminophen_max_2g_day_if_used_at_all_in_active_AUD (AASLD ALD 2019)

Monitoring

Regimen monitoring:
- daily LFT bilirubin INR albumin Cr (Crabb 2020)
- day 7 Lille score calculation (Louvet 2007 PMID 17518367)
- infection surveillance blood urine ascitic cultures (Crabb 2020)
- daily HE grading West Haven (AASLD ALD 2019)
- daily weight and ascites assessment (AASLD ALD 2019)
- AUDIT score at discharge for AUD severity (AASLD ALD 2019)
- glucose q6h on steroids (Crabb 2020)
- MELD daily for transplant candidacy (AASLD ALD 2019)
- social work addiction consult within 24h (AASLD ALD 2019)

Setting (ed) monitoring:
- Continuous SpO2 + CIWA q4h (AASLD ALD 2019)
- Q4-6h vital signs + glucose (Crabb 2020)
- Daily LFTs, INR, Cr, Na, albumin (AASLD ALD 2019)

Follow-up plan: 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)
- Close-out criterion: follow-up scheduled

Monitoring phase: 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)

Disposition

Current setting: ed — Recognize severe AH (DF >=32 or MELD >=21), exclude infection, start thiamine BEFORE glucose, admit, hepatology consult (AASLD ALD 2019)

Disposition criteria:
- Admit floor: severe AH (DF >=32 or MELD >=21) without organ failure (AASLD ALD 2019)
- Admit ICU: HE 3-4, shock, HRS-AKI, variceal bleed (AASLD ALD 2019)
- Outpatient: mild AH (DF <32 + MELD <20) with safe disposition + addiction follow-up scheduled (AASLD ALD 2019)

Escalation triggers (move to higher acuity):
- HE grade 3-4 with airway compromise - ICU + intubation (AASLD ALD 2019)
- HRS-AKI - ICU + terlipressin + albumin (CONFIRM 2022)
- Variceal bleed - ICU + emergent EGD (Baveno VII 2022)
- Septic shock - ICU + broad antibiotics + pressors (Surviving Sepsis 2021)

Earlier-Return Triggers

Return-precaution thresholds (watch for):
- [LIFE_THREATENING] Lille score >=0.45 at day 7 of prednisolone = non-responder; ~75% 6-month mortality on continued steroids (Louvet 2007)
- [LIFE_THREATENING] HRS-AKI per ICA criteria in severe AH (Crabb 2020)
- [SEVERE] Maddrey discriminant function >=32 ( 4.6 x (PT - control PT) + total bilirubin mg/dL ) (Maddrey 1978)

Citations

- AASLD 2019 Practice Guidance: Diagnosis and Treatment of Alcohol-Associated Liver Diseases (Crabb, Hepatology 2020) [PMID:31314133](https://pubmed.ncbi.nlm.nih.gov/31314133/)
- Cited evidence (PMID 25901427) [PMID:25901427](https://pubmed.ncbi.nlm.nih.gov/25901427/)
- Cited evidence (PMID 17518367) [PMID:17518367](https://pubmed.ncbi.nlm.nih.gov/17518367/)
- Cited evidence (PMID 22070476) [PMID:22070476](https://pubmed.ncbi.nlm.nih.gov/22070476/)
- Cited evidence (PMID 352788) [PMID:352788](https://pubmed.ncbi.nlm.nih.gov/352788/)

Last reconciled with current guidelines: 2026-05-26.
References
  • AASLD 2019 Practice Guidance: Diagnosis and Treatment of Alcohol-Associated Liver Diseases (Crabb, Hepatology 2020) — PMID:31314133
  • Cited evidence (PMID 25901427) — PMID:25901427
  • Cited evidence (PMID 17518367) — PMID:17518367
  • Cited evidence (PMID 22070476) — PMID:22070476
  • Cited evidence (PMID 352788) — PMID:352788