The scoring tool is often used in the hospital setting, as these individuals are often quite sick when they reach the disease state that necessitates the use of the Maddrey Score. In short, the Maddrey score helps determine how badly damaged the liver is, so that a plan of care can be developed.
Who Needs a Maddrey Score?
Individuals with alcoholic hepatitis are the patients for whom the Maddrey Score is used. These are patients who have damage to their liver caused by alcoholism, or excessive consumption of alcohol, and are typically experiencing moderate to severe symptoms when the Maddrey score is used.
Some of these individuals will be in the hospital, others will be seen on an outpatient basis. In both cases, they should be receiving care from a provider who specializes in gastroenterology or hepatology. Gastroenterologists care for the entire digestive tract, including the liver, while hepatologists focus on the liver.
What Is Alcoholic Cirrhosis?
Alcoholic cirrhosis is a type of liver disease caused by excessive alcohol consumption. It can range from mild to severe and can cause many problems—including death.
Alcohol causes chronic inflammation of the liver, fatty deposits and can cause scarring to the tissue that makes it difficult for the liver to function properly. In some cases, the liver becomes notably enlarged.
Common Signs and Symptoms of Cirrhosis
There are multiple types of cirrhosis, which may or may not be caused by alcohol intake. Regardless of the cause, patients with cirrhosis typically have the same signs and symptoms, which are typically mild in the initial stages of the disease and dramatically worsen in severe disease.
Right-sided abdominal pain: The liver is located in the right upper abdomen and some patients report that they feel an aching feeling over the liver that increases with worsening disease. Nausea: some patients do experience vomiting, but nausea is more common and may require medication to allow the patient to eat regular meals. Bruising easily: the liver plays a significant role in helping the blood clot after a wound or injury. As cirrhosis worsens, bruising occurs more easily and in some cases, bleeding occurs unexpectedly, without an injury as a trigger. Mental confusion/fogginess: When the liver is unable to do its job, ammonia can build up in the blood, leading to confusion, fatigue, mental cloudiness, and an inability to take care of simple daily tasks. Forgetfulness: When the liver is diseased to the point where it can no longer perform its job completely, symptoms will appear and worsen as the disease does. Medication can be used to improve symptoms. Fatigue/weakness: Fatigue is very common and often is what leads to a diagnosis of cirrhosis. Jaundice (yellowing of the skin): When the liver is no longer able to filter the blood well the skin and other tissues of the body can take on a yellow appearance. This is often first noticed in the whites of the eyes, where the subtle change is the most obvious. Visibly enlarged veins in the belly: Caused by increased blood pressure and congestion in the blood vessels near the liver, the blood vessels in the abdomen become larger and more obvious under the skin. Enlarged veins in the esophagus (esophageal varices): In addition to the veins in the abdomen being congested and enlarged in size, the same can happen to the vessels in the esophagus. When these veins are significantly enlarged there is a risk of life-threatening bleeding, so treatment is often necessary to reduce this risk. Poor appetite, weight loss: Many patients will gain weight due to fluid retention, but others find that they are losing weight due to a lack of appetite and fatigue. Nausea can also lead to weight loss. Breast enlargement in men and women: While the exact cause of this is not clearly understood, cirrhosis leads to hormone imbalance which then leads to a change in breast size. Gas (flatulence) Bleeding: Red blood may or may not be seen. In some, bleeding may present as “coffee grounds” that are seen when vomiting. Others may notice that their stools are no longer brown but become darker or even black, and look sticky or like tar. Both of these are signs of bleeding in the digestive system and should be reported to a healthcare provider. Water retention (ascites): Some patients retain significant fluid, particularly in the abdomen, a condition that can lead to the need to have a procedure to remove the fluid. Itching: This can be a sign that the liver is not filtering the blood well which can be experienced as itching. Swelling in the legs, ankles, and feet: Another sign of fluid retention, swelling in the lower extremities can be a sign of issues with the liver in some individuals. Shortness of breath: Shortness of breath can be an issue if fluid retention in the abdomen makes it difficult to take a deep breath or increases pressure in the belly.
How It’s Calculated
The Maddrey score uses two blood tests to determine the extent of liver damage, bilirubin and prothrombin time.
Bilirubin is an orange pigment that the liver makes when it breaks down hemoglobin (a part of the blood) and it is then excreted in bile. Normally, this is removed from the body but in the case of a damaged liver the bilirubin can build up in the bloodstream causing jaundice.
Prothrombin time is a measure of how quickly the blood clots measured in seconds. One of the functions of the liver is to help blood clot, so longer clotting times are expected when the liver is damaged.
Control is a calculation that the lab uses to determine what “normal” results are at that particular facility, and is not a lab result from the patient’s blood.
The equation used to calculate the Maddrey Score is:
Bilirubin (mg/dL) + 4. 6 times (prothrombin time in seconds minus control)
How It’s Used
When a patient with alcoholic cirrhosis is ill, the Maddrey Score is used to determine if they would benefit from the use of steroids as part of their medication regimen. It also can predict the likelihood of survival, particularly in the three months following the score being calculated.
If the Maddrey score is less than 32, the patient is considered to have mild to moderate alcoholic cirrhosis and would likely not benefit from the use of steroids. Approximately 90 percent of patients who have this score will survive the months immediately following when the score was done.
Unfortunately, a score higher than 32 indicates severe alcoholic liver disease, meaning that the liver has been badly damaged by alcohol. In these cases, about 60-65 percent of patients are alive three months after scoring. It is these patients who are the best candidates for the use of steroids as a part of their treatment. For these patients, the risks of aggressive treatment are outweighed by the potential rewards of longer survival.
It is important to remember that the Maddrey Score is a tool, not an absolute. This means that the score is just one thing a physician or healthcare professional looks at when determining the best course of action. For this reason, you may see a patient with a score of 30 who receives steroids and you may see a different patient with a score above 32 who does not. Steroids have significant side effects, such as dramatically raising blood sugar, which may need to be avoided in some patients.
How to Improve the Maddrey Score
The Maddrey score is not set in stone, nor is it the last word on how a patient’s disease will respond to treatment. The score is a tool used to predict outcomes, but the patient may still be able to alter their disease process in some cases.
For patients with mild disease, a change in lifestyle can create enormous positive changes in the ability of the liver to function and can actually reverse the severity of the disease. In some patients with mild disease stopping alcohol intake can lead to a total reversal of the disease. For patients with moderate to severe disease, it is possible to see liver disease improve for some. For others, lifestyle changes do not lead to improvement but do prevent the disease from worsening—it can be difficult to predict how much improvement will occur.
Stop all alcohol intake. If the individual continues to drink alcohol, the one proven way to stop the worsening of the disease and possibly experience an improvement in liver function is to stop drinking alcohol completely. This means absolutely no alcohol, not even an occasional sip of wine or beer. This total cessation of alcohol may be very difficult but will be absolutely essential to the survival of the patient, as ongoing alcohol use after the diagnosis of alcoholic cirrhosis will only increase the speed with which the patient progresses to the final stages of cirrhosis and eventually death. Low fat/sodium diet. Diet can help control cirrhosis. A diet low in fat and sodium can help slow the worsening of the disease and can reduce the retention of fluid caused by the liver. For individuals who require the removal of fluid from the abdomen, a procedure called a paracentesis, diet can impact how frequently the procedure is necessary by reducing fluid retention. Supplementation. Some individuals with alcoholic cirrhosis are severely malnourished and will see an improvement in their condition with the addition of vitamins and minerals added to the diet as prescribed by a healthcare provider. The source of the malnutrition may be the lack of calories in the form of food, as some individuals with severe alcoholism eat minimally and take most of their calories in the form of alcohol. For others, a poor quality diet or other issues may lead to malnutrition. Adequate calories. For patients with severe disease and a poor appetite, it may be necessary to supplement the diet with drinks such as Ensure or Boost. If the patient is unable to consume enough calories to satisfy the body’s needs, often 2,000 calories or more, they may require tube feeding to increase the number of calories they are taking in. In general, healthy whole foods are preferred over supplement drinks, but for some patients, any food is welcome if they are struggling to take in adequate calories. Liver transplant. The one true cure for cirrhosis, regardless of the cause, is a liver transplant. Transplantation is particularly difficult for individuals with alcoholic cirrhosis because they must abstain from alcohol for a period of time—usually 6 months or longer—to qualify for a transplant. This can be extremely difficult, and many individuals are never able to qualify for a transplant because they are unable to successfully stop drinking alcohol.
The patient must also abstain from alcohol after receiving a new liver, as the new organ can be damaged with alcohol even faster than the original liver due to the medications required to prevent rejection.
A Word from Verywell
The Maddrey Score is just one tool that providers use in the care of patients who are diagnosed with alcoholic liver disease. The score helps determine the severity of the cirrhosis and gives an indication of whether or not steroids should be used for that individual. While this is an important part of the care provided, other factors are just as important or even more important, such as whether the patient continues to drink alcohol, how willing they are to follow instructions and other factors that they cannot change, such as their age.
