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Management bei schwerer alkoholischer Hepatitis

Management of severe alcoholic hepatitis

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Zusammenfassung

Die alkoholische Hepatitis (AH) ist ein klinisches Syndrom, welches durch eine schwere Leberentzündung (dominiert durch Infiltration mit neutrophilen Granulozyten), Leberzellschädigung und Fibrose charakterisiert ist und durch massiven Alkoholkonsum ausgelöst wird. Diese klinisch oft lebensbedrohliche Erkrankung entwickelt sich meist auf dem Boden einer bereits bestehenden Leberzirrhose. Klinische Leitsymptome sind Ikterus, Malaise, Gerinnungsstörung und Enzephalopathie. Typische Komplikationen sind dabei Sepsis und Organversagen und die Mortalität dieser Erkrankung beträgt unverändert bis zu 50 %. Im Vordergrund der Therapie stehen Alkoholabstinenz und supportive Maßnahmen. Kortikosteroide stellen seit Jahrzehnten die einzige Therapieoption dar. Die Indikation für eine Kortikosteroidtherapie wird bei einem Maddrey Score > 32 gestellt und nach 7 Tagen wird diese Therapie je nach Ansprechen (erfaßt über den Lille Score) beendet oder für insgesamt 4 Wochen fortgesetzt. Letzlich ist eine Kortikosteroidtherapie allerdings nur in einer Patientensubgruppe möglich und erfolgreich. Eine frühe Lebertransplantation (innerhalb Tagen bis wenigen Wochen nach Therapieversagen) stellt für streng selektionierte Patienten (keine Komorbiditäten, soziale Integration) eine Therapiealternative dar. In der Pathophysiologie dieser Erkrankung spielen pro-inflammatorische Zytokine wie Tumor Nekrose Faktor-alpha (TNFα) oder Interleukin-1 (IL-1) eine herausragende Rolle und diese Erkrankung ist heute der Prototyp einer zytokin-mediierten Erkrankung. Die Neutralisation dieser Schlüsselzytokine vor allem von IL-1 reflektiert das zur Zeit attraktivste Therapiekonzept für die Zukunft. Es ist zu hoffen, dass bei dieser von der (klinischen) Forschung leider zu sehr vernachlässigten Erkrankung in Zukunft bessere Therapieoptionen zur Verfügung stehen werden

Summary

Severe alcoholic hepatitis is still associated with high mortality and presence of liver failure manifested by jaundice, coagulopathy and encephalopathy is a poor prognostic indicator. The management of these patients includes at first hand several supportive measures as treatment of alcohol withdrawal, administration of fluid and vitamins and admission to an intensive care unit in the unstable patient. Glucocorticoids have been since decades the most intensively studied therapy in alcoholic hepatitis and are effective in certain subgroups. Indication for such a therapy is usually defined on a Maddrey Discriminant Function > 32. The Lille score at day 7 is used to decide whether corticosteroid therapy should be stopped or continued for a 1 month course. Nutritional supplementation is also likely to be beneficial. The main progress in better understanding its pathophysiology has come from cytokine studies. Various proinflammatory cytokines such as tumor necrosis factor-alpha (TNFα) or interleukin-1 (IL-1) have been proposed to play a role in this disease. This advancement has recently led to pilot studies investigating anti-TNF drugs such as pentoxifylline, infliximab (anti-TNF antibody) or etanercept in the treatment of this disease. These studies revealed besides for pentoxifylline rather negative results. Despite this fact, targeting of certain cytokines such as IL-1 remains an attractive treatment concept for this devastating disorder in the future.

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  1. Univ.-Klinik für Innere Medizin I, Endokrinologie, Gastroenterologie & Stoffwechsel, Medizinische Universität, Anichstrasse 35, 6020, Innsbruck, Austria

    Verena Wieser MD &  Herbert Tilg

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  2. Herbert Tilg
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Correspondence to Herbert Tilg.

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Wieser, V., Tilg, H. Management bei schwerer alkoholischer Hepatitis. Wien Med Wochenschr 164, 3–8 (2014). https://doi.org/10.1007/s10354-013-0221-5

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  • DOI: https://doi.org/10.1007/s10354-013-0221-5

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