Snapshot A 35-year-old man is brought to the emergency department for abdominal pain and flu-like symptoms for the past 2 days. He reports that he just returned from a 2-month trip throughout South America. He reports fever, fatigue, malaise, and right upper quadrant pain but denies diarrhea, melena, hematochezia, nausea, vomiting, or weight loss. A physical examination demonstrates tender hepatomegaly and mild scleral icterus. Introduction Overview condition is an acute (temporary) form of hepatitis, which describes the inflammation of the liver tissue treatment is usually supportive and dependent on the etiology Epidemiology etiology viral hepatitides (e.g., HAV, HCV, and HBV) parasites (e.g., toxoplasmosis) alcohol drug-induced (e.g., acetaminophen) autoimmune hepatitis steatohepatitis metabolic disease risk factors alcohol abuse foreign travel intravenous drug use sexual contact Pathogenesis mechanism the specific mechanism of injury depends on the etiology generally, the initial insult results in hepatocyte injury leading to the activation of an inflammatory response, which can become chronic (with subsequent fibrosis and cirrhosis) Associated conditions medical conditions and comorbidities chronic hepatitis fulminant liver failure Prognosis the vast majority of patients with acute hepatitis recover completely without complications overall, low mortality rate but prognosis may be worse if the patient has other comorbidities or initial presenting symptoms such as ascites, edema, or encephalopathy Presentation History recent travel sudden jaundice Symptoms common symptoms initial prodromal phase (flu-like symptoms) fatigue nausea vomiting poor appetite headaches followed by jaundice (1-2 weeks after) right upper quadrant (RUQ) pain Physical exam jaundice scleral icterus hepatomegaly splenomegaly RUQ tenderness fever Imaging Ultrasound indications good initial imaging modality for rule out of other causes of abdominal pain findings hepatomegaly (most sensitive sign) gallbladder wall thickening Studies Serum labs complete blood count (CBC) may demonstrate elevated WBC count with atypical lymphocytosis in viral hepatitis hepatic panel mixed direct and indirect hyperbilirubinemia dramatically elevated aspartate aminotransferase (AST) and alanine aminotransferase (ALT) ALT usually higher than AST if AST:ALT > 2, suspect alcoholic hepatitis hepatitis viral serologies determines which type of virus and the immunity status IgM antibodies are present during early infection IgG antibodies are present and remain after recovery e.g., if a patient is positive for IgG but negative for IgM, the patient is immune via either prior infection or vaccination Serologic Findings Clinical Implications HBV surface antigen Anti-HBV core antibody Active infection Anti-HBV surface antigen antibody Immunity Anti-HBV core antibody HBV e-antigen Highly infectious HCV antibody Exposure Differential Chronic hepatitis key distinguishing factors patient history may reveal a long period of symptoms Gallbladder disease key distinguishing factors ultrasound or other imaging modalities will demonstrate pathology or the presence of stones Treatment Lifestyle supportive care indications especially for patients with acute viral hepatitis and alcoholic hepatitis modalities fluid and electrolyte management treatment of any encephalopathy or coagulopathy monitor and management for alcohol withdrawal and abstain from alcohol nutritional support for acute alcoholic hepatitis thiamine/folate Medical antiviral therapy indications used for the treatment of severe acute hepatitis B modalities nucleoside analogues (e..g, entecavir) pentoxifylline and/or corticosteroids indications used for severe alcoholic hepatitis Complications Pancreatitis Aplastic anemia Peripheral neuropathy Myocarditis
QUESTIONS 1 of 4 1 2 3 4 Previous Next Lab Values Blood Hematologic Cerebrospinal Sweat, Urine, and BMI Blood, Plasma, Serum Reference Range ALT 8-20 U/L Amylase, serum 25-125 U/L AST 8-20 U/L Bilirubin, serum (adult) Total // Direct 0.1-1.0 mg/dL // 0.0-0.3 mg/dL Calcium, serum (Ca2+) 8.4-10.2 mg/dL Cholesterol, serum Rec: < 200 mg/dL Cortisol, serum 0800 h: 5-23 μg/dL //1600 h: 3-15 μg/dL 2000 h: ≤ 50% of 0800 h Creatine kinase, serum Male: 25-90 U/LFemale: 10-70 U/L Creatinine, serum 0.6-1.2 mg/dL Electrolytes, serum Sodium (Na+) 136-145 mEq/L Chloride (Cl-) 95-105 mEq/L Potassium (K+) 3.5-5.0 mEq/L Bicarbonate (HCO3-) 22-28 mEq/L Magnesium (Mg2+) 1.5-2.0 mEq/L Estriol, total, serum (in pregnancy) 24-28 wks // 32-36 wks 30-170 ng/mL // 60-280 ng/mL 28-32 wk // 36-40 wks 40-220 ng/mL // 80-350 ng/mL Ferritin, serum Male: 15-200 ng/mLFemale: 12-150 ng/mL Follicle-stimulating hormone, serum/plasma Male: 4-25 mIU/mL Female: premenopause: 4-30 mIU/mL midcycle peak: 10-90 mIU/mL postmenopause: 40-250 pH 7.35-7.45 PCO2 33-45 mmHg PO2 75-105 mmHg Glucose, serum Fasting: 70-110 mg/dL2-h postprandial:<120 mg/dL Growth hormone - arginine stimulation Fasting: <5 ng/mLProvocative stimuli: > 7ng/mL Immunoglobulins, serum IgA 76-390 mg/dL IgE 0-380 IU/mL IgG 650-1500 mg/dL IgM 40-345 mg/dL Iron 50-170 μg/dL Lactate dehydrogenase, serum 45-90 U/L Luteinizing hormone, serum/plasma Male: 6-23 mIU/mL Female: follicular phase: 5-30 mIU/mL midcycle: 75-150 mIU/mL postmenopause 30-200 mIU/mL Osmolality, serum 275-295 mOsmol/kd H2O Parathyroid hormone, serume, N-terminal 230-630 pg/mL Phosphatase (alkaline), serum (p-NPP at 30° C) 20-70 U/L Phosphorus (inorganic), serum 3.0-4.5 mg/dL Prolactin, serum (hPRL) < 20 ng/mL Proteins, serum Total (recumbent) 6.0-7.8 g/dL Albumin 3.5-5.5 g/dL Globulin 2.3-3.5 g/dL Thyroid-stimulating hormone, serum or plasma .5-5.0 μU/mL Thyroidal iodine (123I) uptake 8%-30% of administered dose/24h Thyroxine (T4), serum 5-12 μg/dL Triglycerides, serum 35-160 mg/dL Triiodothyronine (T3), serum (RIA) 115-190 ng/dL Triiodothyronine (T3) resin uptake 25%-35% Urea nitrogen, serum 7-18 mg/dL Uric acid, serum 3.0-8.2 mg/dL Hematologic Reference Range Bleeding time 2-7 minutes Erythrocyte count Male: 4.3-5.9 million/mm3Female: 3.5-5.5 million mm3 Erythrocyte sedimentation rate (Westergren) Male: 0-15 mm/hFemale: 0-20 mm/h Hematocrit Male: 41%-53%Female: 36%-46% Hemoglobin A1c ≤ 6 % Hemoglobin, blood Male: 13.5-17.5 g/dLFemale: 12.0-16.0 g/dL Hemoglobin, plasma 1-4 mg/dL Leukocyte count and differential Leukocyte count 4,500-11,000/mm3 Segmented neutrophils 54%-62% Bands 3%-5% Eosinophils 1%-3% Basophils 0%-0.75% Lymphocytes 25%-33% Monocytes 3%-7% Mean corpuscular hemoglobin 25.4-34.6 pg/cell Mean corpuscular hemoglobin concentration 31%-36% Hb/cell Mean corpuscular volume 80-100 μm3 Partial thromboplastin time (activated) 25-40 seconds Platelet count 150,000-400,000/mm3 Prothrombin time 11-15 seconds Reticulocyte count 0.5%-1.5% of red cells Thrombin time < 2 seconds deviation from control Volume Plasma Male: 25-43 mL/kgFemale: 28-45 mL/kg Red cell Male: 20-36 mL/kgFemale: 19-31 mL/kg Cerebrospinal Fluid Reference Range Cell count 0-5/mm3 Chloride 118-132 mEq/L Gamma globulin 3%-12% total proteins Glucose 40-70 mg/dL Pressure 70-180 mm H2O Proteins, total < 40 mg/dL Sweat Reference Range Chloride 0-35 mmol/L Urine Calcium 100-300 mg/24 h Chloride Varies with intake Creatinine clearance Male: 97-137 mL/minFemale: 88-128 mL/min Estriol, total (in pregnancy) 30 wks 6-18 mg/24 h 35 wks 9-28 mg/24 h 40 wks 13-42 mg/24 h 17-Hydroxycorticosteroids Male: 3.0-10.0 mg/24 hFemale: 2.0-8.0 mg/24 h 17-Ketosteroids, total Male: 8-20 mg/24 hFemale: 6-15 mg/24 h Osmolality 50-1400 mOsmol/kg H2O Oxalate 8-40 μg/mL Potassium Varies with diet Proteins, total < 150 mg/24 h Sodium Varies with diet Uric acid Varies with diet Body Mass Index (BMI) Adult: 19-25 kg/m2 Calculator ( ) xy AC 7 8 9 ÷ 4 5 6 × 1 2 3 - 0 . = + Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK You have 100% on this question. Just skip this one for now. Take This Question Anyway (M2.GI.4671) A 32-year-old G2P1 at 32 weeks gestation presents to the emergency department with complaints of severe abdominal pain, fatigue, and nausea. Physical examination is significant for profound jaundice and tenderness to palpation of the right upper quadrant of the abdomen. The patient returned 2 weeks ago from a 1 month-long trip to India. She received sporadic pre-natal care while traveling and reports no known complications in her current pregnancy to date. She denies any past medical problems and states that her prior pregnancy proceeded as a normal vaginal birth without any complications. Infection with which of the following organisms would portend the worst prognosis with the highest mortality rate for this patient? Review Topic QID: 107174 Type & Select Correct Answer 1 Hepatitis A 4% (1/27) 2 Hepatitis B 7% (2/27) 3 Hepatitis C 4% (1/27) 4 Hepatitis D 7% (2/27) 5 Hepatitis E 74% (20/27) M2 Select Answer to see Preferred Response SUBMIT RESPONSE 5 You have 100% on this question. Just skip this one for now. Take This Question Anyway (M3.GI.12) A 44-year-old woman presents to the emergency department with jaundice and diffuse abdominal pain. She denies any previous medical problems and says she does not take any medications, drugs, or supplements. Her temperature is 97.6°F (36.4°C), blood pressure is 133/87 mmHg, pulse is 86/min, respirations are 22/min, and oxygen saturation is 100% on room air. Physical exam is notable for sclera which are icteric and there is tenderness to palpation over the right upper quadrant. Laboratory studies are ordered as seen below.Hepatitis B surface antigen: PositiveHepatitis B surface IgG: NegativeHepatitis B core antigen: PositiveHepatitis B core IgG: PositiveHepatitis B E antigen: PositiveHepatitis B E IgG: PositiveWhich of the following is the most likely diagnosis? Review Topic QID: 102718 Type & Select Correct Answer 1 Acute hepatitis B infection 25% (1/4) 2 Chronic hepatitis B infection 25% (1/4) 3 Hepatitis B vaccination 0% (0/4) 4 No hepatitis B vaccination or infection 25% (1/4) 5 Resolved hepatitis B infection 25% (1/4) M2 Select Answer to see Preferred Response SUBMIT RESPONSE 2