Another Round? Liver Biopsy Determined the Diagnosis and Management in Patients With Alcohol Recidivism and Recurrent Acute Jaundice

Abstract

Background: Reports of recurrent severe alcoholic hepatitis (AH) do not include confirmation by liver biopsy. We describe the clinical and histologic features of three patients with recurrent episodes of jaundice and suspected acute liver injury due to alcoholic recidivism. Methods: Evaluation of 120 patients with acute alcoholic liver injury included two with distinct hospitalizations between 2005 and 2012 for the recent onset of jaundice and a suspicion for severe alcoholic hepatitis (AH) defined by a discriminant function (DF) >32 or a MELD score of >18. A third patient later identified is included. Particular to these cases, a liver biopsy was performed during the index and a subsequent episode. Results: The clinical and histologic features for the first and subsequent episodes of acute alcoholic liver injury are presented in Table 1. Each patient had resolution of jaundice within 2-5 months after the first presentation. Recurrent jaundice in the context of alcohol recidivism occurred at an interval of 1-6 years. Patient #1 had cirrhosis and two episodes of biopsy-proven AH with histologic features of hepatocyte ballooning, Mallory-Denk bodies, and neutrophilic lobular inflammation. Treatment with corticosteroids for 7 days on both occasions resulted in partial responses with calculated Lille scores of 0.23 and 0.38, respectively. Patient #2 had two episodes of acute alcoholic fatty liver with cholestasis (AFLC), without histologic evidence of AH. Cholestasis, prominent macrovesicular fat, mild portal fibrosis, and mild lymphocytic lobular inflammation were present. Treatment was supportive. Patient #3 had an initial episode of self-limited jaundice due to AFLC followed by periods of recidivism and three recurrent episodes of jaundice over a period of >6 years. During the second recurrence, a liver biopsy showed AH. A calculated Lille score after 7 days of corticosteroids was 0.21, and 28-day treatment resulted in complete resolution of jaundice.Table 1: Clinical and histologic features of three patients with alcohol recidivism and recurrent episodes of acute jaundice due to alcoholic hepatitis (AH) or alcoholic fatty liver with cholestasis (AFLC)Conclusions: After a first episode of acute alcoholic liver injury, jaundice may recur in patients with alcohol recidivism. The histologic pattern of recurrent liver injury is not always the same. Liver biopsy remains important in evaluating recurrent episodes in order to distinguish between recurrence of the first injury, including AH, or other alcoholic liver diseases, like AFLC, that can have similar clinical presentations.