A 50-year-old man complains of abdominal pain and a 1-week history of black bowel movements, weakness, nausea, and dark colored urine. He reports heavy alcohol consumption. His gait is ataxic. His temperature is 37.9°C, heart rate 70/min, respiratory rate 18/min, and blood pressure 140/60 mm Hg. He is disoriented and has a tender enlarged liver, guaiac-positive stool, and mild ascites. Laboratory test results: WBC, normal; PT and INR, mildly prolonged; AST, 3 times normal; total bilirubin, 2.0; alkaline phosphatase, moderately elevated. Immediate management should include:
Rectal lactulose.
+Abdominal CT with contrast.
+Percutaneous liver biopsy.
+Diagnostic paracentesis.
+Bedside ultrasound.
Alcoholic hepatitis is often associated with additional complicating disease: meningitis, pneumonia, subdural hematomas, peritonitis, and GI bleeding. Hepatic encephalopathy may account for neuropsychiatric symptoms. Treatment is supportive, and unless the disease is clearly mild, hospital admission is justified. Blood cultures should be ordered to evaluate for sepsis. A paracentesis is needed to evaluate for spontaneous bacterial peritonitis. If indicated, a liver biopsy may be performed on an elective basis, but certainly not before reversal of the abnormal coagulation status.