| Pivotal Assessment | Finding | ||||
|---|---|---|---|---|---|
| History | |||||
| Physical Exam | |||||
EKG |
Non-ST Myocardial Infarction | ||||
| Creatinine | Elevated/Normal | ||||
a. History: Weight loss, fever, or arthralgia, are usually experienced only for a few weeks. The presence of such signs for a longer period suggests that the patient is double positive for anti-GBM and anti-myeloperoxidase (MPO-ANCA) and has features of concurrent vasculitis [74].
Differential Diagnosis
Alcoholic Cirrhosis
| Next Pivotal Assessment | Finding | ||||
|---|---|---|---|---|---|
Creatinine |
Elevated/Normal | ||||
Liver tests may show elevation of AST, whereas ALT is usually in the normal range. This is the opposite of what is seen in other liver disorders. Carbohydrate-deficient transferrin is the most reliable marker of chronic alcoholism.
Ultrasound is the first imaging test of choice to assess patients with alcoholic hepatitis; it can be used to exclude gallstones and other biliary tract disorders. A liver biopsy is not always required but is useful for excluding other disorders. A liver biopsy should be done with care as these patients may have coagulopathy and thrombocytopenia.
Several trials and models exist to determine the severity of alcoholic hepatitis, to ascertain which patients would likely benefit from a pharmacological approach. In 1977, the Maddrey discriminant factor (MDF), included serum total bilirubin and prothrombin time to segregate patients with a 28-day mortality risk of greater than 50%. These patients had an MDF greater than 32 and were deemed to benefit from steroid therapy. Subsequent scoring systems included the model for end-stage liver disease (MELD) score, the ABIC score (including the age, bilirubin, international normalized ratio, and the creatinine score), the Glasgow AH score (including the age, bilirubin, international normalized ratio, blood urea nitrogen, and the peripheral white blood count) and the Lille score. The Lille score obtains data from the beginning and end of the first week of steroid therapy to assess response and subsequent need for further steroid therapy. A histological scoring system for the prognosis of patients with alcoholic hepatitis has also been proposed. Various combinations of scoring systems have been studied to predict outcomes accurately, and the combination of the MELD and the Lille score is one. [9][10][11][12]
Recent studies indicate that CRP is a good marker of alcoholic hepatitis.