DDSEP® 8 Quick Quiz

February 2016 Quiz 2

Publish date: January 28, 2016

A 40-year-old woman is admitted for acute alcoholic hepatitis. Workup for other causes of acute and chronic liver disease has been negative. On examination, her skin is revealing for spider angiomas over her chest. She is jaundiced but awake and oriented to person, place, and time. Labs: AST, 249 IU/L; ALT, 114 IU/L; ALP, 163 IU/L; total bilirubin, 20.2 mg/dL; prothrombin time, 23.3 sec; INR, 3.1; creatinine, 1.4 mg/dL; blood and urine alcohol levels are positive. Blood cultures are pending and an initial gram stain shows gram-negative rods. Vitals: temperature, 101.3° F, blood pressure, 103/67 mm Hg; heart rate, 103 beats/min, respiratory rate, 12. Supportive care and antibiotics are initiated. Which of the following is the next most appropriate treatment option for this patient?

Supportive care and antibiotics are initiated. Which of the following is the next most appropriate treatment option for this patient?

A. Observation

B. Prednisone

C. Etanercept

D. Pentoxifylline

E. Propylthiouracil

Q2: ANSWER: D

Critique

This is a patient with severe alcoholic hepatitis complicated by sepsis with a Maddrey’s discriminant function greater than 32. Pentoxifylline 400 mg t.i.d. would be the most appropriate choice for treatment. Pentoxifylline is a nonselective phosphodiesterase inhibitor that decreases tumor necrosis factor gene transcription. In one study of severe alcoholic hepatitis, it appeared to reduce both mortality and renal failure. It may have a beneficial effect in preventing HRS. Prednisone would not be optimal in the setting of active infection and sepsis. Anti-TNF treatment has been associated with increased risk of severe infections and this and propylthiouracil have not shown benefit in the treatment of alcoholic hepatitis. For this patient with severe alcoholic hepatitis, treatment will improve survival and observation would not be adequate.

References

  1. O’Shea R.S., Dasarathy S., McCullough A.J.. Alcoholic liver disease. Hepatology 2010;51:307-28.
  2. Mathurin P., Mendenhall C.L., et al. Corticosteroids improve short-term survival in patients with severe alcoholic hepatitis (AH): individual data analysis of the last three randomized placebo controlled double blind trials of corticosteroids in severe AH. J Hepatol. 2002;36:480-7.

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February 2016 Quiz 1