Hepatitis Alcoholica

The

n e w e ng l a n d j o u r na l

of

m e dic i n e

review article
Medical Progress

Alcoholic Hepatitis
Michael R. Lucey, M.D., Philippe Mathurin, M.D., Ph.D., and Timothy R. Morgan, M.D. xcessive alcohol consumption is the third leading preventable cause of death in the United States.1,2 Alcohol-associated mortality is disproportionately high among young people, andapproximately 30 years of life are lost per alcohol-associated death — or, in the aggregate, 2.3 million years of potential life lost in 2001 in the United States.1 Excess consumption of alcohol is associated with both short-term and long-term liver damage, several types of cancer, unintentional injuries both in the workplace and on the road, domestic and social violence, broken marriages, and damaged socialand family relationships.3 The association between alcohol intake and alcoholic liver disease has been well documented, although cirrhosis of the liver develops in only a small proportion of heavy drinkers.4 The risk of cirrhosis increases proportionally with consumption of more than 30 g of alcohol per day; the highest risk is associated with consumption of more than 120 g per day.4 The pointprevalence of cirrhosis is 1% in persons drinking 30 to 60 g of alcohol a day and up to 5.7% in those consuming 120 g daily. It is presumed that other factors, such as sex,4,5 genetic characteristics,6 and environmental influences (including chronic viral infection),7 play a role in the genesis of alcoholic liver disease. Chronic alcohol use may cause several types of liver injury. Regular alcoholuse, even for just a few days, can result in a fatty liver (also called steatosis), a disorder in which hepatocytes contain macrovesicular droplets of triglycerides. Although alcoholic fatty liver resolves with abstinence, steatosis predisposes people who continue to drink to hepatic fibrosis and cirrhosis.8 This review focuses on alcoholic hepatitis, a treatable form of alcoholic liver disease.Since up to 40% of patients with severe alcoholic hepatitis die within 6 months after the onset of the clinical syndrome, appropriate diagnosis and treatment are essential.

From the Section of Gastroenterology and Hepatology, Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison (M.R.L.); Service des Maladies de l’Appareil Digestif, Hôpital Claude Huriez,INSERM Unité 795, Université Lille 2 (P.M.) — all in Lille, France; and the Gastroenterology Section, Veterans Affairs Long Beach Healthcare System, Long Beach, and the Division of Gastroenterology, University of California, Irvine (T.R.M.) — both in California. Address reprint requests to Dr. Lucey at the Section of Gastroenterology and Hepatology, H6/516 CSC, University of Wisconsin Hospitals andClinics, 600 Highland Ave, Madison, WI 53792, or at mrl@medicine.wisc.edu. N Engl J Med 2009;360:2758-69.
Copyright © 2009 Massachusetts Medical Society.

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Cl inic a l Pr e sen tat ion of A l c ohol ic Hepat i t is
Alcoholic hepatitis is a clinical syndrome of jaundice and liver failure that generally occurs after decades of heavy alcohol use (mean intake, approximately 100 g per day).9Not uncommonly, the patient will have ceased alcohol consumption several weeks before the onset of symptoms. The typical age at presentation is 40 to 60 years. Although female sex is an independent risk factor for alcoholic hepatitis, more men drink to excess, and there are more men than women with alcoholic liver disease.9 The type of alcohol consumed does not appear to affect the risk ofalcoholic hepatitis. The incidence is unknown, but the prevalence was approximately 20% in a cohort of 1604 patients with alcoholism who underwent liver biopsy.9 The cardinal sign of alcoholic hepatitis is the rapid onset of jaundice. Other common signs and symptoms include fever, ascites, and proximal muscle loss. Patients with severe alcoholic hepatitis may have encephalopathy. Typically, the liver is...