Investigation

The investigation of a patient with alcoholic hepatitis should include:

• full blood count:
  • shows polymorph leucocytosis
  • severity of the leucocytosis is proportional to the severity of the hepatitis
    
    
• liver function tests:
  • serum aminotransferases are raised:
    • levels rarely exceed 300 iu/l except when complicated by paracetamol intake, this may be because AST is expressed at lower concentrations in zone 3 hepatocytes
  • AST: ALT ratio exceeds 2
  • gamma glutamyl transferase and serum immunoglobulin A concentrations are often raised (1)
  • ferritin concentration is often markedly raised (above 1000 µg/L) - even in the absence of haemochromatosis (1)
  • raised serum alkaline phosphatase
  • raised serum bilirubin
  • increased prothrombin time - may be a contraindication for liver biopsy
  • decreased serum albumin:
    • the albumin rises as the patient improves
  • raised urea and creatinine predicts the development of the hepato-renal syndrome
    
    
• liver biopsy - definitive diagnosis of alcoholic hepatitis requires a liver biopsy - histological features that are characteristic include inflammation, polymorph infiltration and the presence of hyaline and steatosis (1). Percutaneous biopsy has associated risks including haemorrhage, particularly if the patient has impaired coagulation or ascites. In patients at risk of bleeding then transjugular biopsy is potentially the safer option but requires specialist facilities and expertise. In many district general hospitals where the highly skilled staff required to undertake these procedures may not be available, then it is reasonable for the diagnosis to be made on clinical and biochemical grounds alone (1)

The presence of hyperlipidaemia and haemolysis suggests Zieve's syndrome.

Reference:

1. Drug and Therapeutics Bulletin (2003), 41 (7), 49-52.