Snap Shot A 35-year-old man with duodenal ulcer disease had 10 units of pRBCs transfused for upper GI bleeding 3 months ago. He presents to the ED with flu-like symptoms, malaise, and tender hepatomegaly. Jaundice is present on physical exam. CBC shows leukopenia with relative lymphocytosis. Introduction Inflamation of the liver caused by viruses alcohol drug-induced phenytoin halothane INH methyl-dopa other causes include EBV CMV toxoplasmosis Q fever Rocky Mountain spotted fever autoimmune shock liver secondary to hypoperfusion neoplasm Wilson's disease Risk factors include alcohol foreign travel intravenous drug use sexual contact Presentation Symptoms often starts with viral prodrome symptoms malaise joint pain fatigue nausea vomiting followed by jaundice Physical exam jaundice scleral icterus tender hepatomegaly Evaluation Laboratory CBC elevated WBC with a atypical lymphocytosis in viral hepatitis. hepatic panel mixed direct and indirect hyperbillirubinemia. dramatically elevated AST and ALT transaminasemia is the best marker for hepatitis ALT usually higher than AST AST:ALT > 2 suggests alcoholic hepatitis. hepatitis virus serologies Serologic Findings Clinical Implications HBV surface antigen Active infection anti-HBV surface antigen antibody Immunity anti-HBV core antibody HBV e-antigen Highly infectious HCV antibody Exposure Treatment Acute viral hepatitis: Supportive management without specific antiviral therapy, regardless of viral type fluid and electrolyte management treatment of any existing encephalopathy treatment of any coagulopathy Acute alcoholic hepatitis monitor and manage for alcohol withdrawal fluid and electrolyte management watch out for alcoholic ketoacidosis / respiratory alkalosis nutritional support administer thiamine / folate with first bag of fluids acute alcoholic hepatitis induces catabolic state, so intake can be 1.5x normal GI bleeding prophylaxis with H2 blocker or PPI steroid therapy based on discriminant function score (DF) DF: based on patient's PT and total bilirubin if steroids are contraindicated, consider pentoxifylline