A patient with severe alcoholic hepatitis may experience adrenal insufficiency. This overlaps with critical illness-related corticosteroid insufficiency. The authors are from SMS Medical College in Jaipur, India.

Patient selection: acute alcoholic hepatitis


Patient exclusion: cirrhosis (associated with hepatoadrenal syndrome); high baseline serum cortisol (> 33 micrograms per dL)



(1) severe alcoholic hepatitis with systemic inflammation

(2) relative glucocorticoid deficiency


Hypotheses for relative glucocorticoid deficiency:

(1) reduced secretion (supported by suppressed response to ACTH)

(2) increased demand

(3) resistance to activity

(4) mixed


Criteria for adrenal insufficiency: < 7/dL microgram increase in serum cortisol level from baseline 1 hour after IM injection of 25 IU ACTH.


One manifestation may be a clinical response to exogeneous corticosteroid therapy.


Looking at Figure 2:

(1) A Maddrey discriminant function (DF) <= 32 is associated with a normal response to ACTH.

(2) The response to ACTH can be normal or abnormal with a DF from 33 to 140.

(3) A DF above 140 is associated with an abnormal ACTH response.

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