Introduction

Since 2010 (1), little data has been available in France on the management of severe acute alcoholic hepatitis (SAH). In order to obtain a current "mapping" of the management of severe HAS in France, a practice survey was conducted from 04/2022 to 07/2023.

Aims & Methods

A Google questionnaire pre-established by a working group was sent to all the hepatogastroenterology departments of general hospitals (nUH), the hepatology departments of university hospitals (UH). The results are expressed as means ± SD. Data analysed: demographics, type of practice (university hospital, general hospital), predominant speciality, experience, number of AA treated per centre with corticosteroids (C) or N-acetylcysteine corticosteroids (NAC). Existence of an AA treatment protocol. Systematic use of transjugular liver biopsy (LB), on-site LB, time taken to obtain results. Treatment: use of C alone or C-NAC. Screening for bacterial infections, use of antibiotic therapy (ATB) in the event of infection, time taken to start treatment for AA. Whether or not to use C in antigen-positive HBs patients (with or without pre-emptive treatment). Interruption of C in the event of an intermediate Lille score at D7. Indication for transfer to a liver transplant centre.

Results

465 respondents (R): 40 years (12.5); 50% M, 50% F, UH 53.3%, nUH 46.7%, hepatologists 57%, gastroenterologists 39%, juniors 21%. Number of AA treated with CS or CS NAC 25 (0 to 300); the number of AA treated in UH was higher than in non UH: 34 (29), nUH 15.4 (13.4), p < 0.001. Treatment protocol for AA, 62% (University Hospital) vs 42% (Hospital), p < 0.001. LB systematically performed: 98% AA vs 50% other, p < 0.001. Time taken to obtain LB (days): 3.4 (UH) vs 4.9 (nUH), p < 0.001. Nutritional status was assessed by 98% of patients. A systematic chest CT scan was routinely requested by 34% of patients in the event of suspected pulmonary infection (UH versus nUH ns); 83% of patients waited 4 days (2-6) before starting treatment in the event of documented infection. Treatment: C alone 70% of patients (UH vs nUH ns), NAC use: UH 40% vs nUH 47.3% (ns). Treatment protocol for alcohol withdrawal syndrome: 86.3% nUH vs 76.3% UH (p < 0.01). CS stopped in the event of an intermediate Lille score at D7: 80% nUH vs 77% UH; ns. 69% of R's were responsible for initiating treatment. 68.2% of R were responsible for initiating treatment; 64.7% in UH vs 72.3% (NS); 80.6% senior doctors vs 20.4% junior doctors (p<0.001). 62% of R used pre-emptive treatment before CS in the case of a positive HBs antigen; 59.4% in UH vs 65% in nUH (p=0.004) and 76% used upper gastrointestinal endoscopy if there had been none previously, 77% in UH vs 75% nUH (p=0.782).

Conclusion

The results of this study of national practice carried out in a large sample of doctors practising in or outside university hospitals show a disparity in the use of LB in cases of suspected severe AA, since 50% of R outside university hospitals do not use LB, mainly because of the absence of local possibilities. Dual C-NAC therapy is used fairly frequently. There is a disparity between university hospitals and general hospitals in the management of alcohol withdrawal syndrome and pre-emptive treatment in cases of positive HBs antigen. This study provides an update on the management of severe AA in France.

References

E.Nguyen-Khac et al J Hepatol 2010 (abstract)