Snapshot A 35-year-old man presents to his primary care physician for routine check-up. During this visit, review of systems reveals that he has been feeling excessively fatigued with weight loss, lack of energy, and vague abdominal discomfort. He has a history of alcohol abuse as well as acute hepatitis. On physical exam, he has mild tenderness to palpation and no hepatomegaly. Laboratory evaluation shows elevated liver enzymes and positive anti-HCV antibodies. Introduction Overview chronic hepatitis is defined by hepatic inflammation of > 6-month duration Epidemiology risk factors alcohol use IV drug use international travel unprotected sexual practices etiology hepatitis C virus (most common) hepatitis B virus with or without hepatitis D coinfection nonalcoholic steatohepatitis alcoholic hepatitis autoimmune hepatitis alpha-1-antitrypsin deficiency Wilson disease hemochromatosis medications, when taken long term isoniazid methyldopa nitrofurantoin Pathogenesis mechanism chronic hepatitis can last for years but remain mild without significant hepatic injury chronic hepatitis can also result in cirrhosis, liver failure, and increase the risk for hepatocellular carcinoma Associated conditions hepatocellular carcinoma Presentation History patients may have a history of acute hepatitis Symptoms common symptoms malaise poor appetite fatigue abdominal discomfort Physical exam inspection jaundice is rare palpation hepatomegaly Imaging Ultrasound of liver indications screen for hepatocellular carcinoma findings liver mass Studies Serum labs liver function tests elevated AST and ALT (at least 3x higher than normal) degree of elevation does not correlate with disease severity AST:ALT > 2 suggests alcoholic hepatitis elevated prothrombin time (PT) hepatitis viral panel HBV quantitation of HBsAg and presence of anti-HBc IgM/IgG, anti-HBs Ab HCV presence of anti-HCV Ab, genotyping, and HCV RNA quantitation Invasive studies liver biopsy confirm diagnosis and assess for degree of inflammation/cirrhosis Differential Acute hepatitis key distinguishing factor acute onset with flu-like symptoms, jaundice, abdominal pain, and transaminitis Treatment Management approach depends on underlying etiology see individual topics for treatment regimens Lifestyle weight loss alcohol cessation Medical antiviral treatment indications chronic hepatitis B monitor therapy with HBV DNA and alanine aminotransferase (ALT) levels chronic hepatitis C based on genotype, previous treatment history and, if cirrhosis is present, degree of severity based on MELD-Na score examples of regimens include interferon + ribavirin immunosuppression indication autoimmune hepatitis Surgical liver transplant indication end-stage liver disease and/or for those refractory to medical therapy. Complications Cirrhosis Hepatocellular carcinoma Portal hypertension
QUESTIONS 1 of 2 1 2 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 . = + You have 100% on this question. Just skip this one for now. Take This Question Anyway (M2.GI.49) A 42-year-old male with a history significant for IV drug use comes to the emergency department complaining of persistent fatigue and malaise for the past three weeks. On physical exam, you observe a lethargic male with icteric sclera and hepatomegaly. AST and ALT are elevated at 600 and 750, respectively. HCV RNA is positive. Albumin is 3.8 g/dL and PT is 12. A liver biopsy shows significant inflammation with bridging fibrosis. What is the most appropriate treatment at this time? Review Topic QID: 106336 Type & Select Correct Answer 1 Interferon 6% (4/71) 2 Ribavirin 4% (3/71) 3 Lamivudine 0% (0/71) 4 Combined interferon and ribavirin 69% (49/71) 5 Combined interferon and lamivudine 20% (14/71) M2 Select Answer to see Preferred Response SUBMIT RESPONSE 4 You have 100% on this question. Just skip this one for now. Take This Question Anyway (M2.GI.27) A 46-year-old female with a history of hypertension and asthma presents to her primary care physician for a health maintenance visit. She states that she has no current complaints and generally feels very healthy. The physician obtains routine blood work, which demonstrates elevated transaminases. The physician should obtain further history about all of the following EXCEPT: Review Topic QID: 104818 Type & Select Correct Answer 1 Alcohol intake 9% (2/23) 2 IV drug use 4% (1/23) 3 International travel 4% (1/23) 4 Sex practices 9% (2/23) 5 Smoking history 70% (16/23) M2 Select Answer to see Preferred Response SUBMIT RESPONSE 5