barcelona . spain - European Association for the Study of the Liver
barcelona . spain - European Association for the Study of the Liver
barcelona . spain - European Association for the Study of the Liver
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BARCELONA . SPAIN<br />
100 POSTGRADUATE COURSE SYLLABUS ALCOHOLIC LIVER DISEASE 101<br />
APRIL 18 - 19/2012 THE INTERNATIONAL LIVER CONGRESS TM 2012<br />
(GAHS) has been validated in <strong>the</strong> UK. Among patients with a DF ≥ 32 and a GAHS ≥ 9 prognosis was<br />
extremely poor if <strong>the</strong>y were not treated with corticosteroids. The ABIC score identifies patients with a 90 day<br />
and 1 year survival rate <strong>of</strong> respectively 100%, 70% and 25% (21). The authors retrospectively evaluated<br />
<strong>the</strong> response to corticosteroids and found that this was 100%, 71% and 33% in <strong>the</strong> patients with low,<br />
intermediate and high risk <strong>of</strong> death respectively. For <strong>the</strong> MELD, <strong>the</strong>re is uncertainly about <strong>the</strong> threshold <strong>for</strong><br />
initiating corticosteroids. Finally one score allow to discriminate <strong>the</strong> respons rate to corticosteroids during<br />
treatment: a Lille score at day 7 <strong>of</strong> ≤ 0.16 discriminated <strong>the</strong> best responders (19).<br />
Table 1: Prognostic scores used <strong>for</strong> patients with alcoholic hepatitis<br />
Infection is commonly seen in patients with severe ASH and is found in around 25% <strong>of</strong> <strong>the</strong> patients. Recent<br />
data demonstrated that after control <strong>of</strong> <strong>the</strong> infection corticosteroids are not contraindicated <strong>for</strong> <strong>the</strong> treatment<br />
<strong>of</strong> ASH. Infection during steroid treatment however was <strong>the</strong> explanation <strong>of</strong> non-respons to corticosteroids<br />
in agreement <strong>of</strong> <strong>the</strong> concept <strong>of</strong> <strong>the</strong> ACLF (22).<br />
c.The value <strong>of</strong> liver biopsy in patients with ASH.<br />
Although liver biopsy is not required to establish <strong>the</strong> diagnosis <strong>of</strong> ASH and a well validated histological<br />
classification is still lacking, biopsy can be helpful. Indeed as already mentioned not every sudden<br />
exacerbation <strong>of</strong> alcoholic cirrhosis is due to severe ASH (2). Biopsy will not only allow a correct diagnosis<br />
<strong>of</strong> ASH, it is helpfull to define <strong>the</strong> severity <strong>of</strong> ASH and <strong>the</strong> presence <strong>of</strong> liver polymorphonucclear infiltrate<br />
has prognostic value (23). Biopsy can also recognize <strong>the</strong> patients in a pre-cirrotic stage which might have<br />
a better outcome. Finally, biopsy can also help to diagnose sepsis in an early stage which is useful to<br />
recognize ACLF (24).<br />
CONCLUSIONS<br />
Several precipitating events can provoke ACLF in patients with alcoholic liver disease. One <strong>of</strong> <strong>the</strong> frequent<br />
triggers is severe ASH. Early and aggressive control <strong>of</strong> <strong>the</strong>se precipitating events can reverse ACLF. In<br />
patients with ASH and bad prognoses corticosteroids prevents ACLF.<br />
Several disease specific prognostic scores are available <strong>for</strong> patients with ASH. Some <strong>of</strong> <strong>the</strong>m are helpful<br />
to select <strong>the</strong> best candidates <strong>for</strong> corticosteroid and one score (Lille) can select non-responders early during<br />
treatment.<br />
Figure 1<br />
Different outcome <strong>of</strong> patients with chronic liver failure due to chronic hepatitis decompensation (CHD) or<br />
acute-on-chronic liver failure (ACLF) due to alcohol (Katoonizadeh et al GUT 2010).<br />
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