Severe alcoholic hepatitis: current perspectives

Figures & data

Figure 1 Descriptions and definition of standard drinks and their respective alcohol content.

Figure 2 Etiopathogenesis of alcoholic hepatitis.

Abbreviations: CXCL-1, chemokine (C-X-C motif) ligand 1; IL, interleukin; MIP, macrophage inflammatory protein; mi-RNA, microRNA; ROS, reactive oxygen species; DAMPs, damage-associated molecular pattern molecules; PAMPs, pathogen-associated molecular pattern molecules.

Figure 3 Histopathology of alcoholic hepatitis with added insult(s). (A) Extensive zone 3 porto-central necrosis with mixed inflammation in a patient with severe alcoholic hepatitis as per clinical history and biochemical features, but with added ayurvedic herbal medicine related injury (haematoxylin and eosin stain, H&E, 20×). (B) Severe focal lymphocytic aggregates seen in a patient with severe alcoholic hepatitis with reactivation of hepatitis B virus infection (H&E, 20×). (C) Lymphocytic and eosinophilic inflammation in a patient with alcoholic hepatitis with super added polyherbal medicine related drug-induced liver injury (H&E, 40×). (D) Lymphoplasmacytic interface hepatitis due to hepatitis C virus infection in the background of balloon-degeneration of hepatocytes in a patient with severe alcoholic hepatitis (H&E, 40×).

Figure 4 Histopathology of alcoholic hepatitis. (A) Severe macrovesicular steatosis (haematoxylin and eosin stain, H&E, 40×). (B) Ballooning of hepatocytes (Masson-trichrome stain [MTS], 20×). (C) Foamy degeneration of alcoholic hepatitis (H&E, 40×). (D) Severe cholestasis of alcoholic hepatitis associated with foamy degeneration (H&E, 40×). (E) Mallory-Denk bodies seen in a patient with alcoholic hepatitis (H&E, 40×). (F) Chicken-wire or pericellular fibrosis of alcoholic hepatitis (MTS, 40×).

Box 1 Summary of treatments for alcoholic hepatitis

Approved treatments for alcoholic hepatitis

None

Recommended treatment for alcoholic hepatitis

Corticosteroids

Treatments with a survival benefit; require further studies

Corticosteroids + N-acetyl cysteine

Granulocyte-colony-stimulating factor (GCSF)

Liver transplantation

Fecal microbiota transplantation

Recommended treatments with survival benefit beyond one month

None

Treatments with survival benefit beyond one month; require further studies

Granulocyte-colony-stimulating factor (GCSF)

Liver transplantation

Fecal microbiota transplantation

Treatments with survival benefit beyond one year, requires further studies

Liver transplantation

Faecal microbiota transplantation

Treatments with unknown outcomes, currently in trials

Extracorporeal cellular therapy (ELAD)

Rifaximin

Amoxycillin and clavulanate

Probiotics + prebiotics

Anti-lipopolysaccharide bound to IgG fraction of bovine colostrum

Anakinra

Metadoxine

Interleukin 22

Canakinumab

Cenicriviroc

Micro-RNA inhibitors

Treatments not recommended and without survival benefit

Ursodeoxycholic acid

Silymarin (milk thistle extract)

Vitamin E

N-acetyl cysteine

S-adenosyl methionine

Pentoxyfilline

Etanercept/infliximab

Selonsertib

Emricasan

Propylthiouracil

Insulin/glucagon/growth hormone

Anabolic steroids

Colchicine

Figure 5 Procedure for nasoduodenal fecal microbiota transplantation in alcoholic hepatitis. Before the procedure, a prokinetic is administered. (A) Blending of freshly collected (30 g) of stool sample with normal saline for 2 mins. (B) Filteration of the stool suspension to remove solid vegetable matter followed by (C) repeat filtration through sterile gauze to homogenize the suspension. (D): filtered stool suspension packed into sterile containers. (E) Infusion of stool suspension through a nasoduodenal tube in a patient with alcoholic hepatitis in grade 2 hepatic encephalopathy. (F) Post infusion, 50 mL normal saline flush is performed.

Notes: Informed consent from the patient to use pertinent images in this figure was obtained before preparation of the manuscript. Informed consent of the other personnel in the image were not required, given masking of their faces. All photographs are copyright 2018 Dr Cyriac Abby Philips.