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World J Hepatol. Oct 27, 2014; 6(10): 688-695
Published online Oct 27, 2014. doi: 10.4254/wjh.v6.i10.688
Severe alcoholic hepatitis-current concepts, diagnosis and treatment options
Won Kim, Dong Joon Kim
Won Kim, Department of Internal Medicine, Seoul Metropolitan Government Seoul National University Boramae Medical Center, Seoul 156-707, South Korea
Dong Joon Kim, Department of Internal Medicine, Hallym University College of Medicine, Chuncheon 200-704, South Korea
Author contributions: Kim W collected data, reviewed literatures, and wrote the manuscript; Kim DJ designed this review, appraised critically and revised the manuscript.
Correspondence to: Dong Joon Kim, MD, PhD, Professor, Department of Internal Medicine, Hallym University College of Medicine, #153 Gyo-dong, Chuncheon-si, Gangwon-do, Chuncheon 200-704, South Korea. djkim@hallym.ac.kr
Telephone: +82-33-2405646 Fax: +82-33-2418064
Received: August 22, 2014
Revised: September 2, 2014
Accepted: September 16, 2014
Published online: October 27, 2014
Processing time: 92 Days and 12.9 Hours
Abstract

Alcoholic hepatitis (AH) is an acute hepatic manifestation occurring from heavy alcohol ingestion. Alcoholic steatohepatitis (ASH) is histologically characterized by steatosis, inflammation, and fibrosis in the liver. Despite the wide range of severity at presentation, those with severe ASH (Maddrey’s discriminant function ≥ 32) typically present with fever, jaundice, and abdominal tenderness. Alcohol abstinence is the cornerstone of therapy for AH and, in the milder forms, is sufficient for clinical recovery. Severe ASH may progress to multi-organ failure including acute kidney injury and infection. Thus, infection and renal failure have a major impact on survival and should be closely monitored in patients with severe ASH. Patients with severe ASH have a reported short-term mortality of up to 40%-50%. Severe ASH at risk of early death should be identified by one of the available prognostic scoring systems before considering specific therapies. Corticosteroids are the mainstay of treatment for severe ASH. When corticosteroids are contraindicated, pentoxifylline may be alternatively used. Responsiveness to steroids should be assessed at day 7 and stopping rules based on Lille score should come into action. Strategically, future studies for patients with severe ASH should focus on suppressing inflammation based on cytokine profiles, balancing hepatocellular death and regeneration, limiting activation of the innate immune response, and maintaining gut mucosal integrity.

Keywords: Alcoholic steatohepatitis; Infection; Renal failure; Corticosteroids; Pentoxifylline

Core tip: We should further explore novel molecular targets to restore altered gut mucosal integrity, suppress inflammation based on cytokine profiles, promote hepatic regeneration, and limit innate immune responses in severe alcoholic steatohepatitis.