Updated: 10/9/2019

Chronic Hepatitis

Topic
Review Topic
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Questions
2
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Evidence
8
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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
 

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Questions (2)
Lab Values
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/L
Female: 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/mL
Female: 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/dL
2-h postprandial:<120 mg/dL
Growth hormone - arginine stimulation Fasting: <5 ng/mL
Provocative 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/mm3
Female: 3.5-5.5 million mm3
Erythrocyte sedimentation rate (Westergren) Male: 0-15 mm/h
Female: 0-20 mm/h
Hematocrit Male: 41%-53%
Female: 36%-46%
Hemoglobin A1c ≤ 6 %
Hemoglobin, blood Male: 13.5-17.5 g/dL
Female: 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/kg
Female: 28-45 mL/kg
Red cell Male: 20-36 mL/kg
Female: 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/min
Female: 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 h
Female: 2.0-8.0 mg/24 h
17-Ketosteroids, total Male: 8-20 mg/24 h
Female: 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
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(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
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

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SUBMIT RESPONSE 4

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(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
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

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SUBMIT RESPONSE 5
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