Stickel and Seitz proposed an algorithm for managing a patient with alcoholic steatohepatitis (ASH). Many patients improve on discontinuing alcohol and providing adequate nutrition, while others continue to deteriorate. The authors are from the Universities of Bern and Heidelberg in Germany.


Patient selection: alcoholic steatohepatitis


Liver biopsy is not mandatory but may be helpful in staging the severity of the liver disease.



(1) low vs high risk (based on MELD, Glasgow Alcoholic Hepatitis Score, other score, presence of hepatic encephalopathy)

(2) nutritional status

(3) response to abstinence and other therapies

(4) comorbid conditions such as gastrointestinal bleeding


All patients should become abstinent of alcohol. Management may require treatment for delirium tremens (DTs) during the initial withdrawal period. Long-term follow-up includes supportive care and monitoring for hepatocellular carcinoma if cirrhosis is present.


Comorbid conditions should be treated.


Nutritional supplementation (35 kcal per kg body weight, 1.5 g per kg protein per day) is provided to a person with evidence of malnutrition or high risk ASH.


A patient with high risk ASH is treated with prednisolone 40 mg/day. This is continued for 4 weeks and tapered for 2 weeks if there are no contraindications. Steroid therapy is stopped if there is no fall in the serum bilirubin witin 1 week of starting therapy.


A high risk patient who fails to respond to conservative management should be evaluated for suitability of liver transplant.


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