Alcohol-associated hepatitis

Cirrhosis is end-stage hepatic fibrosis with regenerative nodules, staged as compensated or decompensated by the onset of ascites, variceal hemorrhage, encephalopathy, or jaundice. Severity is graded by Child-Pugh class and MELD, and management centers on treating the underlying cause, surveillance for varices and hepatocellular carcinoma, and timely transplant referral once decompensation appears.

Hepatic encephalopathy is a reversible spectrum of brain dysfunction from insufficient hepatic clearance and portosystemic shunting of gut-derived toxins, graded by the West Haven criteria and almost always triggered by an identifiable precipitant such as infection, gastrointestinal bleeding, constipation, or an electrolyte disturbance. Diagnosis is clinical, and management proceeds by treating the precipitant first, then titrating lactulose and adding rifaximin for recurrence prevention.

Portal hypertension is elevated pressure in the portal venous system, most often from cirrhosis, that drives the major decompensating complications of chronic liver disease: varices, ascites, splenomegaly, and encephalopathy. Diagnosis rests on imaging and endoscopy for its downstream signs, and management combines treating the underlying cause with nonselective beta-blockade and, for refractory complications, TIPS.

Spontaneous bacterial peritonitis is a monomicrobial infection of cirrhotic ascitic fluid without a surgical source, diagnosed by an ascitic fluid neutrophil count of 250 cells/microL or higher on paracentesis. Treatment is prompt IV third-generation cephalosporin plus IV albumin in patients with renal or hepatic dysfunction, followed by indefinite secondary antibiotic prophylaxis because recurrence is common.

Hepatorenal syndrome is functional renal failure in a patient with cirrhosis and ascites, driven by splanchnic vasodilation and compensatory renal vasoconstriction, and it is diagnosed only after excluding shock, nephrotoxins, and structural kidney disease and after creatinine fails to improve with diuretic withdrawal and an albumin challenge. Treatment is a splanchnic vasoconstrictor (terlipressin first-line) with intravenous albumin as a bridge to liver transplantation, the only curative therapy.

Gastroesophageal varices are dilated portosystemic collateral veins that form as portal pressure rises in cirrhosis, and their rupture causes acute variceal hemorrhage, a GI emergency treated with vasoactive therapy, prophylactic antibiotics, and urgent endoscopic band ligation. Screening endoscopy in cirrhotics guides primary prophylaxis with a nonselective beta-blocker or ligation, and survivors of a bleed require combined beta-blocker and serial ligation for secondary prophylaxis.

Alcohol use disorder is a chronic pattern of drinking meeting 2 or more of 11 DSM-5 criteria within a 1-year period, screened with the CAGE or AUDIT-C and confirmed by history. First-line management combines a brief behavioral intervention and cognitive behavioral therapy with naltrexone or acamprosate, reserving disulfiram for highly motivated patients who can maintain abstinence.

Alcohol withdrawal syndrome is a staged, timeline-bound hyperexcitability state that follows abrupt cessation or reduction of heavy alcohol use, progressing from minor symptoms through alcoholic hallucinosis and withdrawal seizures to delirium tremens, a medical emergency with mortality as high as 5%. Diagnosis is clinical and severity is graded with the CIWA-Ar; first-line treatment is symptom-triggered benzodiazepine dosing plus thiamine given before glucose.