Alcohol remains the most commonly used psychoactive substance and accounted for nearly 200,000 emergency department (ED) visits in France in 2025, representing approximately 0.9% of all ED activity. During the conference Urgences26, experts reviewed practical strategies for recognizing and managing acute alcoholic hepatitis (AAH), acute alcohol intoxication, and alcohol withdrawal while emphasizing the importance of avoiding diagnostic bias.

Recognizing AAH

France records approximately 15,000 new cases of symptomatic AAH annually. In severe cases, untreated disease has a 1-month mortality rate of 30%-50%.

“AAH is a diagnosis of exclusion and should not be made prematurely,” said Edouard Lansiaux, MD, emergency physician at the Lille University Hospital, Lille, France.

Clinical features include jaundice developing within the previous 3 months, intermittent low-grade fever, poor general condition, right upper quadrant tenderness with or without hepatomegaly, and clinical signs of underlying cirrhosis.

Laboratory findings typically include moderate elevations in aspartate aminotransferase (AST), an AST to alanine aminotransferase ratio greater than 1.5, elevated total bilirubin, hypoalbuminemia, prolonged international normalized ratio, and increased gamma glutamyl transferase and mean corpuscular volume.

AAH should be considered in patients with a history of alcohol consumption exceeding 40 g/d for women or 60 g/d for men for more than 6 months, with abstinence lasting fewer than 8 weeks.

Lansiaux emphasized that infection must be excluded before corticosteroid therapy is initiated.

“Because fever is not always present, clinicians should rule out infection through appropriate investigations, including blood and urine cultures and diagnostic paracentesis when ascites is present, before starting corticosteroids,” he said. Other causes of AAH, including viral hepatitis and drug-induced liver injury, should also be excluded.

Because many patients present during alcohol withdrawal, withdrawal severity should be assessed using the Clinical Institute Withdrawal Assessment for Alcohol Revised (CIWA Ar) scale. Disease severity should also be assessed using validated prognostic tools, including the Maddrey Discriminant Function, Model for End-Stage Liver Disease, Glasgow Alcoholic Hepatitis, and Lille scores. Since these scores are dynamic, they should be assessed at admission and after 7 days of corticosteroid therapy to assess the treatment response.

The treatment strategy for severe AAH involves a combination of corticosteroids and N-acetylcysteine rather than corticosteroids alone.

Lansiaux also advocated liver transplantation for carefully selected patients who do not respond to medical therapy — in accordance with the EASL (European Association for the Study of the Liver) selection criteria. The recommendation was based on a study that showed that the 6-month survival rate was 77% among patients undergoing early liver transplantation compared with 23% among those who did not receive early liver transplantation.

Acute Alcohol Intoxication

Mélanie Roussel, MD, emergency physician at Rouen University Hospital, Rouen, France, cautioned clinicians against dismissing intoxicated patients.

“We need to avoid anchoring bias,” she said. “Patients should not simply be left to sober up. A careful history, including information from witnesses when available, and a thorough physical examination are essential, particularly to identify associated trauma.”

According to a 2008 study, alcohol intoxication must be confirmed by a blood alcohol concentration test, given that there is no reliable correlation between blood alcohol concentration and clinical signs.

Routine laboratory testing is not recommended for uncomplicated intoxication, and management should instead focus on repeated clinical assessments and appropriate monitoring.

Potential complications include atrial fibrillation, aspiration pneumonia, acute gastritis, Mallory Weiss syndrome, AAH, seizures, impaired consciousness, and coma.

Researchers also emphasized the importance of evaluating patients for hypoglycemia and electrolyte abnormalities, including hypernatremia and hyponatremia, alcoholic ketoacidosis, hypothermia, and traumatic injuries.

“In dehydrated patients, intravenous fluids do not accelerate alcohol clearance and may worsen metabolic disturbances,” Roussel said.

She stressed that discharge decisions require particular caution because alcohol intoxication can mask serious underlying illnesses.

“Alcohol use carries one of the highest risks for underestimating clinical severity,” she said. “Patients should be discharged only after they have regained decision making capacity and serious underlying conditions have been excluded.”

Preventing Delirium Tremens (DT)

Éric Thibaud, MD, emergency physician at Hôpitaux Civils de Colmar, Colmar, France, highlighted the importance of early recognition and treatment of alcohol withdrawal.

According to a Norwegian cohort study, approximately 5% of patients treated for alcohol dependence developed DT, with a 3-year mortality rate of 25%.

Withdrawal symptoms generally develop within 7 days after alcohol cessation. Researchers recommend repeated assessment every 30 minutes to 2 hours using either the Cushman score or the CIWA Ar scale.

Risk factors for DT include unplanned or inadequately managed alcohol withdrawal during hospitalization, hypokalemia, thrombocytopenia, and a history of DT.

The management of uncomplicated withdrawal aims to prevent progression to severe withdrawal and its complications. Researchers recommended the following:

• Adequate hydration, approximately 2 L/d, with correction of electrolyte abnormalities
• Routine thiamine (vitamin B1) supplementation at a minimum dose of 300 mg/d to prevent Wernicke-Korsakoff syndrome
• Benzodiazepines when clinically indicated rather than as routine treatment

Long-acting benzodiazepines, such as diazepam, are preferred for most patients. Short-acting agents, including oxazepam and lorazepam, are preferred for patients with liver disease, respiratory disease, advanced age, or obesity because of their more predictable pharmacokinetic profiles.

Medications used to aid abstinence are not indicated for acute withdrawal.

The speakers reported having no relevant conflicts of interest.

This story was translated from Medscape’s French edition.