A 48-year-old man with alcoholic hepatitis (AST 320 U/L, ALT 180 U/L, bilirubin 8.5 mg/dL, INR 1.8) is admitted for management. To assess disease severity and predict 28-day mortality, which investigation is most appropriate?

Explanation

## Prognostic Assessment in Acute Alcoholic Hepatitis **Key Point:** Discriminant Function (DF) score and MELD score are the validated prognostic tools for assessing severity and predicting mortality in acute alcoholic hepatitis. DF is specifically designed for alcoholic hepatitis; MELD is used for cirrhosis and transplant allocation. ### Discriminant Function Score (DF) **Formula:** $$DF = (PT_{patient} - PT_{control}) \times 4.6 + Bilirubin (mg/dL)$$ **Interpretation:** - **DF ≥ 32:** High mortality risk (28-day mortality ~35–50%) - **DF < 32:** Lower mortality risk (28-day mortality ~5–10%) **High-Yield:** DF score was developed specifically for acute alcoholic hepatitis and is superior to individual parameters for prognostic stratification. A DF ≥ 32 indicates need for corticosteroid therapy (prednisolone 40 mg/day × 4 weeks). ### MELD Score (Model for End-Stage Liver Disease) **Formula:** $$MELD = 3.78 \times \ln(Bilirubin) + 11.2 \times \ln(INR) + 9.57 \times \ln(Creatinine) + 6.43$$ **Use:** Cirrhosis severity, transplant urgency, and general prognosis. Less specific for acute alcoholic hepatitis than DF. ### Comparison of Prognostic Tools | Tool | Best Use | Limitation | | --- | --- | --- | | **DF Score** | Acute alcoholic hepatitis; predicts response to steroids | Requires PT values; not standardized globally | | **MELD Score** | Cirrhosis severity, transplant allocation | Less sensitive for acute alcoholic hepatitis | | **Albumin + PT alone** | Supportive data only; insufficient for prognosis | Individual parameters lack predictive power | | **Liver biopsy** | Confirms alcoholic hepatitis histologically | Invasive; not needed for prognostic assessment; high bleeding risk | **Clinical Pearl:** In acute alcoholic hepatitis with DF ≥ 32, corticosteroids (prednisolone) improve 28-day survival. Biopsy confirms the diagnosis but does not change acute management and carries bleeding risk in coagulopathic patients. **Mnemonic:** **MELD = Mortality Estimate for Liver Disease** — remember it for cirrhosis and transplant; **DF = Discriminant Function** — remember it for acute alcoholic hepatitis. **Warning:** Do not confuse DF with MELD. DF is the gold standard for acute alcoholic hepatitis prognosis; MELD is for chronic cirrhosis and transplant listing.