Alcoholic & MASLD liver disease — severe alcoholic hepatitis, Maddrey, Lille and corticosteroids

Diagnosis: severe alcoholic hepatitis (AH) on a background of alcohol-related liver disease. The pattern is classic — AST 195, ALT 70 (ratio over 2, both under 300), a GGT of 610 and MCV of 109 fL, with jaundice (bilirubin 320), tender hepatomegaly, fever and leucocytosis, in a man drinking 80–100 units/week. The low albumin (26), INR 2.1 and thrombocytopenia (95) indicate established cirrhosis with decompensation.^[1]

Immediate assessment and resuscitation (ABCDE).

1. Airway/Breathing — he is grade I–II encephalopathic; protect the airway, give high-flow oxygen if hypoxic.
2. Circulation — two large-bore cannulae; group and save; correct hypotension with albumin.
3. Exclude and treat infection and GI bleed BEFORE any corticosteroid. This is the cardinal safety step. Send blood, urine and ascitic cultures; chest X-ray; ascitic tap for cell count (SBP if neutrophils over 250/mm³); and arrange upper-GI endoscopy if any sign of bleeding. Steroids are contraindicated in uncontrolled sepsis or active GI haemorrhage.^[1]
4. Thiamine BEFORE glucose — thiamine 100 mg IV/PO daily for 3–5 days; always precede any glucose load to prevent Wernicke encephalopathy.
5. Correct glucose, potassium, magnesium, phosphate (phosphate bottoms out with refeeding); start enteral high-protein, high-energy feeding (35 kcal/kg/day, 1.2–1.5 g/kg/day protein) — malnutrition drives mortality.
6. Manage alcohol withdrawal with a CIWA-Ar-guided, symptom-triggered benzodiazepine regimen (chlordiazepoxide PO, or lorazepam in severe liver failure).^[1]

Severity grading — Maddrey Discriminant Function.^[5]

Maddrey DF = 4.6 x (PT − control PT) + total bilirubin (mg/dL)

= 4.6 x (24 − 12) + (320 micromol/L ÷ 17.1 = 18.7 mg/dL) = 4.6 x 12 + 18.7 = 55.2 + 18.7 = about 74 (well over 32).

Severe alcoholic hepatitis confirmed. The MELD (also high here, given the bilirubin and INR) corroborates severity.

Decision to use corticosteroids. For Maddrey 32 or more, the standard is prednisolone 40 mg PO daily for 28 days (then taper), after excluding infection and GI bleed. The STOPAH trial (Thursz, NEJM 2015) established that prednisolone improves 28-day mortality in responders (no benefit at 90 days or 1 year; pentoxifylline had no benefit). Many units add N-acetylcysteine as an adjunct (reduces infection).^[3]

Day 7 — the Lille score gauges response.^[4]

Calculate the Lille score at day 7 from age, albumin, bilirubin evolution (day 0 to day 7), renal function, prothrombin time and baseline bilirubin.

• Lille 0.45 or below = responder → complete the 28-day course.
• Lille over 0.45 = non-responder → corticosteroids are futile (6-month mortality approaches 75 percent) → discontinue and consider early liver transplant assessment in selected patients.

Stepwise definitive management (after the acute episode).

1. Complete and sustained abstinence — the single biggest determinant of long-term survival; pair with structured addiction care (motivational interviewing, mutual-aid; naltrexone or acamprosate once acute liver failure is excluded; avoid disulfiram).
2. Nutrition and rehab — continued high-protein feeding; treat sarcopenia; folate replacement.
3. Treat cirrhosis and its complications — begin 6-monthly hepatocellular carcinoma surveillance (ultrasound plus alpha-fetoprotein); variceal screening (OGD); vaccinate against HAV, HBV, pneumococcus, annual influenza.
4. Transplant assessment for decompensation or in the AH non-responder (many centres require a 6-month abstinence period, though early transplantation in selected severe AH is increasingly accepted).