Acute Hepatitis in the Hospitalized Patient: Triage, Scores, and the Critical Race Against Liver Failure (ALF vs. ACLF)

In this episode of Hospital Medicine Unplugged, we sprint through acute hepatitis—find the cause fast, stabilize early, risk-stratify smart, treat the etiology, and don’t miss ALF.

We open with the do-firsts: airway/breathing/circulation, focused exam (jaundice, asterixis, volume), and a broad lab bundle—AST/ALT, bilirubin, INR/PT, albumin, CBC, BMP, glucose, acetaminophen level, pregnancy test when relevant. Send viral serologies (HAV IgM, HBsAg + anti-HBc IgM, HCV Ab → HCV RNA, HEV IgM/RNA, HDV testing if HBV+). Image with RUQ ultrasound to exclude biliary obstruction and vascular issues. Flag precipitating drugs and toxins early.

Call the diagnosis and the risk: AH and viral hepatitis (A–E) dominate admissions. Use MELD, Maddrey DF, ABIC, Glasgow for alcohol-associated hepatitis (AH); reassess steroid response with the Lille score on day 7. For any patient with coagulopathy and encephalopathy, think acute liver failure (ALF) and call the transplant center early.

Supportive care—build the foundation: • Hemodynamics + glucose (avoid hypotonic fluids; prevent hypoglycemia). • Nutrition: aggressive protein/energy support; adjust for severe hyperammonemia. • Infection vigilance—low threshold to culture and treat; infections drive mortality in AH/ALF. • Manage HE, AKI, SIRS fast; avoid routine INR correction unless procedures planned.

Alcohol-associated hepatitis (AH) moves: • Corticosteroids: prednisolone 40 mg daily for 28 days if Maddrey ≥32 or MELD ≥20 and no contraindications (active infection, GI bleed, severe AKI, uncontrolled sepsis). • Day-7 Lille: non-responder → stop steroids. • Adjuncts (e.g., N-acetylcysteine) may add short-term benefit; evidence is limited—not standard alone. • Early liver transplant: consider in severe, non-responding patients after multidisciplinary evaluation and commitment to abstinence care. • Always pair with addiction medicine, withdrawal management, vitamins (thiamine), and alcohol cessation program.

Acute viral hepatitis plays: • Acute HBV: mostly supportive; antivirals (entecavir/tenofovir) for severe/fulminant disease or high-risk reactivation. • HDV: no proven acute therapy beyond HBV agents; investigational drugs not for ALF. • HCV: supportive in the acute setting; DAA therapy may be considered selectively. • HAV/HEV: supportive care; watch for ALF in vulnerable hosts (pregnancy for HEV).

ALF protocol—don’t blink: • ICU, early airway, head-of-bed up, tight sodium/glucose control, neuro-monitoring. • CRRT for hyperammonemia/AKI; consider high-volume plasma exchange when transplant isn’t imminent. • Use King’s College + MELD to guide transplant activation.

Complications you must prevent: cerebral edema, infection/sepsis, AKI/HRS, hypoglycemia, ARDS, shock. These—not the transaminases—set the mortality curve.

System moves that stick: (1) standardized acute hepatitis order set (labs/viral panel/US + acetaminophen level); (2) steroid checklist for AH (indications/contraindications + Lille day 7 stop rule); (3) infection screen q24–48h in AH/ALF; (4) automatic transplant alert for ALF criteria; (5) nutrition + addiction consults on day 0; (6) discharge bundle: vaccinate (HAV/HBV as indicated), alcohol cessation plan, cirrhosis education, and close hepatology follow-up.

Fast, score-guided, and etiology-targeted—stabilize first, prove the cause, treat what you find, and escalate to transplant before the cliff.