1 Division of Gastroenterology and Hepatology, Johns Hopkins University School of Medicine, Baltimore, MD, USA.
2 Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA.
J Intensive Care Med. 2019 Apr;34(4):277-291. doi: 10.1177/0885066618780339. Epub 2018 Jun 7.
Acute alcoholic hepatitis is a syndrome of jaundice and hepatic decompensation that occurs with excessive alcohol consumption. The diagnosis can be made with a combination of clinical characteristics and laboratory studies, though biopsy may be required in unclear cases. Acute alcoholic hepatitis can range from mild to severe disease, as determined by a Maddrey discriminant function ≥32. Mild forms can be managed with supportive care and abstinence from alcohol. While mild form has an overall good prognosis, severe alcoholic hepatitis is associated with an extremely high short-term mortality of up to 50%. Additional complications of severe alcoholic hepatitis can include hepatic encephalopathy, gastrointestinal bleeding, renal failure, and infection; these patients frequently require intensive care unit admission. Corticosteroids may have short-term benefit in this group of patients if there are no contraindications; however, a subset of patients do not respond to steroids. New emerging therapies, which target hepatic regeneration, bile acid metabolism, and extracorporeal liver support, are being investigated. Liver transplantation for alcoholic liver disease was traditionally only considered in patients who have achieved 6 months of abstinence, in part due to social and ethical concerns regarding the use of a limited resource. However, the majority of patients with severe alcoholic hepatitis who fail medical therapy will not live long enough to meet this requirement. Recent studies have demonstrated that early liver transplantation in carefully selected patients with severe alcoholic hepatitis who fail medical therapy can provide a significant survival benefit and yields survival outcomes comparable to liver transplantation for other indications, with 6-month survival rates ranging from 77% to 100%. Alcohol relapse posttransplantation remains an important challenge, and heavy consumption can contribute to graft loss and mortality. Future investigation should address the substantial post-liver transplantation recidivism rate, from improving selection criteria to increasing posttransplantation substance abuse treatment resources.
急性酒精性肝炎是一种由于过度饮酒引起的黄疸和肝功能失代偿的综合征。该诊断可通过临床特征和实验室研究相结合得出，但在不明确的情况下可能需要进行活检。急性酒精性肝炎可从轻到重，具体取决于 Maddrey 判别函数≥32。轻度病例可通过支持性治疗和戒酒来控制。虽然轻度病例的总体预后良好，但严重的酒精性肝炎与极高的短期死亡率（高达 50%）相关。严重酒精性肝炎的其他并发症包括肝性脑病、胃肠道出血、肾衰竭和感染；这些患者经常需要入住重症监护病房。如果没有禁忌症，皮质类固醇可能对这组患者有短期益处；然而，有一部分患者对类固醇没有反应。新出现的针对肝再生、胆汁酸代谢和体外肝脏支持的治疗方法正在研究中。由于对使用有限资源的社会和伦理问题的担忧，传统上只有在患者戒酒 6 个月后才会考虑对酒精性肝病进行肝移植。然而，大多数因药物治疗失败而患有严重酒精性肝炎的患者不会活足够长的时间来满足这一要求。最近的研究表明，在经过精心挑选的因药物治疗失败而患有严重酒精性肝炎的患者中，早期进行肝移植可以显著提高生存率，并获得与其他适应证的肝移植相当的生存结果，6 个月生存率从 77%到 100%不等。肝移植后酒精复发仍然是一个重要的挑战，大量饮酒会导致移植物丢失和死亡。未来的研究应该解决肝移植后复发率高的问题，从改进选择标准到增加肝移植后物质滥用治疗资源。
