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  • A 40-year-old obese woman presents to her family medicine doctor for intermittent abdominal pain for the past few months as well as fatigue. She has a past medical history of hyperlipidemia, diabetes, and hypertension. She has been trying to lose weight but has not been successful. She reports drinking alcohol socially, on average 2 times per month. On exam, she is not jaundiced and has no tenderness to palpation. Her liver is noted to be enlarged. Laboratory evaluation reveals mildly elevated liver enzymes, and she is referred for liver biopsy to confirm the diagnosis of nonalcoholic steatohepatitis. (Chronic hepatitis)
Introduction
  • Overview
    • acute hepatitis
      • acute inflammation of the liver
    • chronic hepatitis
      • > 6-month duration of liver inflammation
  • Epidemiology
    • etiology
      • viral hepatitides (e.g., HAV, HCV, and HBV)
        • chronic (HCV and HBV +/- HDV)
      • parasites (e.g., toxoplasmosis)
      • alcohol
      • drug-induced
        • acute (e.g., acetaminophen)
        • chronic (e.g., isoniazid, methyldopa, and nitrofurantoin)
      • autoimmune hepatitis 
      • nonalcoholic steatohepatitis
      • metabolic disease
      • Wilson disease
      • hemochromatosis
      • alpha-1-antitrypsin deficiency
    • 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)
  • Prognosis
    • vast majority of patients with acute hepatitis recover without complications
    • some may develop chronic hepatitis
      • of these, many may have longterm chronic hepatitis without significant liver injury
      • however, chronic hepatitis increases the risk of liver failure, cirrhosis, and hepatocellular carcinoma
Presentation
  • Acute hepatitis
    • history
      • recent travel
      • sudden jaundice
    • symptoms
      • prodrome (flu-like symptoms)
        • fatigue
        • fever
        • nausea
        • vomiting
        • poor appetite
        • headache
      • followed by jaundice (1-2 weeks after prodrome)
        • right upper quadrant pain
        • hepatosplenomegaly
  • Chronic hepatitis
    • history
      • history of acute hepatitis
    • symptoms
      • malaise
      • poor appetite
      • fatigue
      • vague abdominal discomfort
      • jaundice is rare
      • may have hepatomegaly
Imaging
  • Ultrasound of liver
    • indications
      • chronic hepatitis
      • screen for hepatocellular carcinoma
    • findings
      • liver mass
      • hepatomegaly
Studies
  • Serum labs
    • complete blood count (CBC)
      • elevated WBC count with atypical lymphocytes in acute viral hepatitis
    • liver function panel
      • acute and chronic hepatitis
        • elevated AST and ALT
        • if AST:ALT>2, suspect alcoholic hepatitis
    • autoimmune hepatitis antibodies
      • anti-smooth muscle antibody
      • anti-nuclear antibody
    • hepatitis viral serologies
      • determines type of virus and immunity status
      • IgM antibodies are present during early infection
      • IgG antibodies are present and remain after recovery
 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
  • Gallbladder disease
    • key distinguishing factors
      • ultrasound or other imaging modalities with pathology of the biliary system or presence of stones
Treatment
  • Management approach
    • management depends on etiology of acute or chronic hepatitis
    • all patients with chronic liver disease should undergo HAV and HBV vaccines
  • Medical
    • supportive care
      • indication
        • acute viral hepatitis or alcoholic hepatitis
      • modalities
        • fluid and electrolyte management
        • treatment of encephalopathy or coagulopathy
        • nutritional support for acute alcoholic hepatitis
    • antiviral treatment
      • indication
        • treat hepatitis B or C
      • modalities
        • interferon + ribavirin or sofosbuvir for hepatitis C infection
        • other antivirals such as lamivudine or tenofovir for hepatitis B infection
    • immunosuppression
      • indication
        • autoimmune hepatitis
      • modalities
        • corticosteroids
        • azathioprine
Complications
  • Hepatocellular carcinoma
  • Cirrhosis
 

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Questions (3)
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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(M1.GI.42) A 51-year-old male with an unknown past medical history presents to a free medical clinic because he is concerned about recent changes to his health. He states that over the past year he has noticed that his eyes appear yellow in color and he has seemed to put on a large amount of weight. He denies any alcohol use but endorses previous and continuing IV drug use. On exam, the patient's vitals are shown as Temp: 36 deg C, HR: 81 bpm, BP: 121/90 mmHg, RR: 11, SaO2: 99% on RA. The physician observes the findings shown in Figure A and B. Furthermore, when the patient holds his hands as demonstrated in Figure C, they oscillate as though he is slapping the air. A liver biopsy is subsequently obtained which is demonstrated in figure D. Which of the following vaccines should this patient receive? Review Topic

QID: 104833
FIGURES:
1

Subunit vaccine and inactivated vaccine

31%

(27/87)

2

Inactivated vaccine only

23%

(20/87)

3

Toxoid vaccine and live attenuated vaccine

10%

(9/87)

4

Conjugate vaccine and toxoid vaccine

24%

(21/87)

5

Live attenuated vaccine only

7%

(6/87)

M1

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SUBMIT RESPONSE 1

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(M1.GI.7) A pathologist is reviewing a number of unlabeled liver biopsy slides which need to be assigned to the correct patient. Which of the following slides best corresponds to a patient who has a history of type II diabetes, obesity, and hyperlipidemia but no history of alcohol intake or liver pathology? Review Topic

QID: 104798
FIGURES:
1

Figure A

23%

(32/141)

2

Figure B

8%

(11/141)

3

Figure C

8%

(11/141)

4

Figure D

9%

(12/141)

5

Figure E

50%

(71/141)

M1

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SUBMIT RESPONSE 5
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