Snapshot A 35-year-old man presents to the hepatology clinic for follow-up after a recent hospital discharge for acute tricuspid valve endocarditis. He has an extensive history of intravenous heroin use. He reports having multiple sexual partners. He appears jaundiced. Lab results obtained during his hospitalization revealed a positive result for anti-HCV antibodies. Subsequent HCV genotyping and HCV RNA levels for this patient reveal genotype 1 and RNA levels of 100,000,000 IU/mL. Introduction Chronic viral hepatitis defined by presence of viral markers for more than six months Causes include: HCV HBV more severe with HDV co-infection Other liver disease etiologies or risk factors may coexist: drug-induced autoimmune alcohol Wilson's hemachromatosis alpha-1-antitrypsin deficiency HIV cancer Presentation Physical exam jaundice scleral icterus hepatomegaly decreased estrogen breakdown (hyperestrinism) gynecomastia testicular atrophy palmar erythema spider angiomas decreased body hair Evaluation CBC elevated WBC with atypical lymphocytosis in viral hepatitis Liver function tests mixed direct and indirect hyperbillirubinemia transaminasemia is the best marker for hepatitis elevated AST and ALT (at least 3x higher than normal) degree of elevation does NOT correlate with severity of disease AST:ALT > 2 suggests alcoholic hepatitis elevated prothrombin time (PT) degree of prolongation DOES correlate with severity of disease Hepatitides viral panel HBV: quantitation of HBs Ag and presence of anti-HBc IgM / IgG, anti-HBs Ab HCV: presence of anti-HCV Ab, genotyping, and HCV RNA quantitation Liver biopsy for evidence of cirrhosis Treatment Chronic hepatitis B: tenofovir +/- lamivudine (3TC) lamivudine alone not recommended due to rapid development of resistance 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 see Step 1 discussion of mechanisms of direct-acting antivirals for HCV first-line treatment for most cases involves sofosbuvir +/- ledipasvir +/- ribavirin monitor therapy with HCV RNA and ALT levels Liver transplant for end-stage liver disease and/or for those refractory to medical therapy.