Overindulgence in alcohol is a serious public health issue. It is the cause of 5.1% of DALYs (Disability Adjusted Life Years) and 5.9 percent of all deaths globally (WHO, 2014). Excessive alcohol consumption is a leading cause of more than 200 illnesses and injuries. Excessive alcohol consumption trails before only tobacco as the largest modifiable risk factor for morbidity and mortality worldwide. Drinking Alcohol has been recognized as one of the priority modifiable risk factors for reducing the burden of NCDs.

It is estimated that around 1/3rd of the male population in South Asian countries drink alcohol. In addition, there is an increasing trend of alcohol consumption among women in those nations . Research indicates that in low- and middle-income countries (LMIC), there is a comparatively higher burden of disease per liter of alcohol consumption. It was recommended that addressing excessive alcohol consumption should serve as a cost-effective and effective strategy to reduce the thrust of disease in LMIC[1].There has always been a strong correlation between national alcohol consumption and deaths from cirrhosis.

In recent decades, Alcohol-associated fatty liver disease, steatohepatitis, and more advanced liver diseases like cirrhosis and fibrosis are all included in the category of alcohol associated liver diseases (ALD), which is a group of illnesses linked to long-term alcohol use [2]

In 1793, Matthew Baillie identified the link between alcohol consumption and liver cirrhosis[3]. The severe type of alcohol-related liver disease known as alcoholic hepatitis (AH) is marked by inflammation and necrosis of the liver cells. It can quickly advance to liver failure, cirrhosis, and fibrosis. Accurate early diagnosis and severity assessment are vital for both prognosis and management of acute alcoholic hepatitis (AAH). Finding patients who are at a high risk of dying soon is essential for enhancing treatment plans and achieving better results because of the substantial morbidity and mortality linked to AH.

Various prognostic models have been devised to forecast the mortality risk in patients with acute hepatitis (AH). Notably, the Modified Discriminant Function (MDF) and the Glasgow Alcoholic Hepatitis Score (GAHS) are extensively acknowledged and employed. To emphasize the clinical utility, comparative efficacy, and possible limitations of these scores, this introduction will examine how these scores are evaluated in predicting three-month mortality among AH patients. Due to its rising incidence, which is consistent with the global 3 trends of increasing alcohol consumption, alcoholic hepatitis is a serious global health concern. The impact of AH on patient health and mortality is only one aspect of its burden; another is the significant amount of healthcare resources that it requires. Up to 40% of patients with severe AH will within three months of their diagnosis, making the mortality rate exceptionally high [4]. Predicting outcomes in AH accurately and early on is therefore essential. Early and accurate prognostication in AH is, therefore, a pivotal aspect of managing the disease, guiding interventions ranging from pharmacotherapy to liver transplantation.

Modified Discriminant Function (MDF), which is intended to forecast short-term mortality by taking into account the extent of liver inflammation and injury. To identify patients with severe AH who may benefit from corticosteroid therapy, the MDF score— which has a cutoff value of 32—is calculated using serum bilirubin level and prothrombin time[5]. Although the MDF score has long been a mainstay in the treatment for acute hepatitis caused by alcohol, its shortcomings in forecasting mortality have been recognized, leading to the investigation of additional or different prognostic models.

An alternative prognostic tool that includes factors like age, blood urea nitrogen, serum bilirubin, prothromb in time, and peripheral white blood cell count is the Glasgow Alcoholic Hepatitis Score (GAHS). Research has indicated that GAHS, as opposed to the MDF, may provide better predictive accuracy for short-term mortality, which could lead to 4 more sophisticated clinical decision-making [6]. Renal function and leukocytosis are now included in the GAHS as prognostic indicators, reflecting the multifactorial nature of AH and its systemic implications and offering a more thorough evaluation of patient risk.

Results from comparisons between MDF and GAHS have been inconsistent, with some research indicating that GAHS may be a better prognostic measure for predicting three month mortality in patients with AH [7].The discussion is still ongoing, though, as additional research emphasizes the value of clinical judgment and the possible advantages of combining prognostic scores for the best possible patient assessment [8]. The selection of a prognostic model can have a substantial impact on clinical decisions, such as the start of particular treatments like pentoxifylline or corticosteroids, or whether to consider liver transplantation for patients who qualify.

Aims and Objectives of the Study:

1. To evaluate the accuracy of Glasgow alcoholic Hepatitis Score and Modified Discriminant Function Score in predicting mortality among alcoholic hepatitis patients.
2. To compare Glasgow Alcoholic Hepatitis score with Modified Discriminant Function score in predicting mortality among alcoholic hepatitis patients.

Source of data: Data collection was conducted among all inpatients diagnosed with alcoholic hepatitis admitted to Department of General Medicine at HIMS Hassan.

Study type: A longitudinal cross-sectional study

Sampling type: Non-probability sampling technique

Study Period: 01 Year

Estimation of sample size: The sample size was determined based on the sensitivity and prevalence rates collected from a previous study. The sensitivity was reported at 93.33%, and the prevalence of the condition 46 was 30%. With a confidence level (Z) of 1.96 and a desired accuracy (W) of 5%, sample size (n) was determined using the formula: Rounding off to 140 participants sample size for the study.

Inclusion criteria:

1. Aged ≥18 years
2. Were admitted under the Department of General Medicine at HIMS.
3. Had been consuming alcohol in quantities greater than 80g/day for 8 years, as determined by the AUDIT C questionnaire ≥8 were selected.
4. Had serum bilirubin levels more than 80 micromol/L (4.7 mg/dl).
5. Had aspartate aminotransferase (AST) levels lower than 500 U/L.

Exclusion criteria:

1. We’re not willing to participate.
2. Consumed alcohol in quantities less than 20g/day.
3. Had a history of hepatotoxic drug intake.
4. Tested positive for HbsAg or Anti-HCV.
5. Had a history of gastrointestinal bleeding.
6. Were diagnosed with liver malignancy.
7. Had an inpatient stay of less than 48 hours.

METHODOLOGY:

Eligible individuals were provided with an information sheet and a consent form. Upon giving informed consent, they were included in the study. The AUDIT-C questionnaire was administered to assess alcohol consumption levels and subjects with score ≥8 then underwent a detailed history elicitation, General physical examination, lab investigations, and imaging studies to confirm my diagnosis of alcoholic hepatitis. Prognostic scores, including the Maddrey's Discriminant Function (mDF) and the Glasgow Alcoholic Hepatitis Score (GAHS), were calculated on the 1st day of admission. Patients with mDF ≥ 32 and GAHS ≥ 9 were identified as high risk and followed until 3 months at one monthly interval.

Statistical Analysis:

Data were entered into an Excel sheet and analyzed using SPSS version 17.0 Statistics software. The analysis employed descriptive statistical tools such as frequency, percentage, standard deviation, and mean. Logistics regression method was used for inferential statistics. For comparison and association tests, unpaired t-tests were applied for parametric data, while chi-square tests were used for non-parametric data. A p-value of <0.05 was considered statistically significant, indicating that the observed differences or associations were unlikely to have occurred by chance.

Table 1: Laboratory parameters and their mean(±SD)

Table 2: Distribution of participants according to GAHS and mDF Scores

Table 3: Distribution of participants according to mortality outcomes based on GAHS and mDF scores

Table 4: Univariate and Multivariate Logistic Regression Analysis to assess association of variables with mortality

Table 5: Baseline Laboratory Investigations and their Association with Mortality

This study aimed to evaluate the accuracy of the Glasgow Alcoholic Hepatitis Score (GAHS) and the Modified Discriminant Function (mDF) score in predicting the mortality among patients with alcoholic hepatitis. The findings demonstrate that both GAHS and mDF are effective tools for predicting mortality in this patient population.

The demographic characteristics of the study participants are consistent with previous studies on alcoholic hepatitis. The majority of participants were males (92.9%), which aligns with the male predominance reported in previous other studies as well. Mean age of the participants (42.5 ± 9.8 years) is comparable to the age range reported in the literature[9-10] .

The clinical characteristics of the participants, including AST, ALT, total bilirubin, serum urea, serum creatinine, PT, INR, and WBC, were discovered to be significantly related to mortality. These findings are accordant with previous studies that have identified these parameters as important prognostic factors in alcoholic hepatitis[11]. In a study by Forrest et al., AST, bilirubin, urea, and WBC were found to be significantly related to mortality at 28 and 84 days after admission.

The GAHS and mDF scores were confirmed as significant predictors of mortality in this study. Majority of the participants (60.7%) had a GAHS score less than 9, while 39.3% had a score ≥ 9. Similarly, 26.4% had an mDF score less than 32, while 73.6% had a score ≥ 32. These findings are accordant with the cut-off values used in preceding studies [12]. In a study by Dunn et al., a GAHS score ≥ 9 was associated with a significantly higher mortality rate compared to a score less than 9 (25% vs. 7%, p <0.001) [13].

Predictive accuracy of GAHS and mDF scores was determined using various metrics that included sensitivity, specificity, positive predictive value (PPV), negative predictive 63 value (NPV), and area under ROC curve (AUC). The GAHS demonstrated superior performance compared to mDF, with sensitivity of 92.3%, specificity of 96.5%, PPV of 86.2%, NPV of 98.2%, and AUC of 0.95 (p=0.02). These all findings were consistent with past studies that have reported the high predictive accuracy of GAHS.

Univariate and multivariate logistic regression analyses confirmed that GAHS, mDF, age, and serum bilirubin are significant predictors of mortality in alcoholic hepatitis patients. These findings are in line with previous studies that have identified these factors as important prognostic indicators[14]. In a study by Dominguez et al., GAHS (OR: 7.2, 95% CI: 3.2- 16.3, p<0.001), age (OR: 1.1, 95% CI: 1.0-1.2, p=0.002), and serum bilirubin (OR: 1.3, 95% CI: 1.1-1.5, p <0.001) were found to be independent predictors of mortality in multivariate analysis[15] .

The baseline laboratory investigations demonstrated significant differences between participants who survived and those who died. Participants who died had significantly higher levels of AST, ALT, total bilirubin, serum urea, serum creatinine, PT, INR, and WBC compared to those who survived. These findings are consistent with previous studies that have reported the association between these parameters and mortality in alcoholic hepatitis.

The subgroup analysis based on the extent of liver disease revealed a significant association between the severity of liver disease and mortality rates. Participants with mild, moderate, and severe liver disease had mortality rates of 5%, 15%, and 30%, respectively (p <0.001). These findings are accordant to past studies that have demonstrated the impact of liver disease severity on mortality in alcoholic hepatitis.

In conclusion, this study confirms the accuracy and utility of the Glasgow Alcoholic Hepatitis Score (GAHS) and the Modified Discriminant Function (mDF) score in predicting the mortality among patients with alcoholic hepatitis. The GAHS demonstrated superior predictive performance compared to mDF, with high sensitivity, specificity, and area under the ROC curve. The study also identified several clinical and laboratory parameters that are significantly associated with mortality, including age, serum bilirubin, AST, ALT, serum urea, serum creatinine, PT, INR, and WBC. Univariate along with multivariate logistic regression analyses established that GAHS, mDF, age, and serum bilirubin are significant predictors of mortality. The severity of liver disease was found to be an important predictor of mortality, with higher mortality rates observed among patients with severe liver disease. These findings highlight the importance of early identification of high-risk patients using prognostic scores and the implementation of appropriate therapeutic interventions to improve outcomes in patients diagnosed with alcoholic hepatitis. The GAHS and mDF scores, along with other clinical and laboratory parameters, can be utilized to guide clinical decision making and optimize treatment strategies for patients with alcoholic hepatitis. Further ahead research is needed to validate these findings in larger, multicenter studies and to explore the potential impact of novel therapeutic interventions on mortality in this patient population

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