Snapshot 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
QUESTIONS 1 of 3 1 2 3 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 . = + Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK You have 100% on this question. Just skip this one for now. Take This Question Anyway (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: A B C D Type & Select Correct Answer 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 Select Answer to see Preferred Response SUBMIT RESPONSE 1 You have 100% on this question. Just skip this one for now. Take This Question Anyway (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: A B C D E Type & Select Correct Answer 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 Select Answer to see Preferred Response SUBMIT RESPONSE 5
PMID: 1531090 N. Engl. J. Med.. 1992 Feb;326(8):507-12. [PMID]1531090[/PMID] A randomized trial of prednisolone in patients with severe alcoholic hepatitis. Ramond MJ Poynard T Rueff B Mathurin P Théodore C Chaput JC Benhamou JP Gastrointestinal - Hepatitis Ramond MJ 1992