Updated: 12/28/2017

Hepatitis

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Snapshot
  • A 35-year-old with duodenal ulcer diseae had a 10 unit blood transfusin for upper GI bleeding 3 months ago. He presents with flu-like symptoms, malaise, and tender hepatomegaly. Labs show an atypical lymphocytosis.
Introduction
  • Inflamation of the liver caused by
    • viruses
      • see Hepatitis viruses topic
    • drug-induced
      • isoniazid, halothane, methyldopa, acetaminophen
    • alcohol
    • autoimmune
      • most often seen in young women
      • HLA DR3, DR4 association
      • can be combined with other autoimmune disorders (e.g. Grave's disease)
    • neonatal
      • associated with CMV, inborn errors of metabolism
    • other causes include
      • mononucleosis
      • Metabolic syndrome - nonalcoholc steatohepatitish (NASH) 
      • Wilson's Disease
  • Risk factors
    • IV drug use
    • alcohol
    • foreign travel
Presentation
  • Symptoms
    • often starts with viral prodrome symptoms
      • malaise/fatigue
      • joint pain
      • nausea/vomiting
  • Physical exam
    • jaundice
      • scleral icterus
    • tender hepatomegaly
Evaluation
  • Labs
    • ↑ WBC with a atypical lymphocytosis in viral hepatitis
    • mixed direct and indirect hyperbillirubinemia
      • conjugated:unconjugated billirubin ratio 0.2-0.5
    • ↑↑↑ elevated AST and ALT (ALT>AST)
      • AST:ALT > 2 suggests alcoholic hepatitis
      • transaminasemia is the best marker for hepatitis
  • Hepatitis B virus serologies
    • HBV surface antigen (HBsAg)= active infection
      • alone indicates early exposure
      • if it remains past acute phase may indicate carrier status
        • HBsAg + HBcAb = healthy carrier
        • HBsAg + HBcAb + HBeAg/HBV DNA = infective carrier
    • HBV envelope antigen/HBV DNA (HBeAg/HBV DNA) = highly infectious
      • are the only infectious particles of the virus
    • anti-HBV surface antibody (HBsAb)= immunity
      • alone indicates immunity from vaccine
        • vacine is a recombinant HBsAb produced by yeast
    • anti-HBV core antibody (HBcAb) = immunity
      • presence indicates recovery from prior exposure
  • Other hepatitis serologies
    • see Hepatitis viruses topic
  • Autoimmune hepatitis serologies
    • anti-smooth muscle antibody
    • anti-nuclear antiboby

Treatment
  • Treatment varries based on etiology
    • HBV
      • pegalated alpha-interferon + / - lamivudine 
        • decrease liklihood of developing chronic hepatitis
    • HCV 
      • pegalated alpha-interferon + ribavirin
      • sofosbuvir
      • simeprevir
      • ledipasvir
    • autoimmune
      • steroids + azathioprine
    • most other causes
      • rest and wait for the resolution of symptoms
      • steroids for severe alchoholic hepatitis
    • Chronic liver disease - must admister HAV and HBV vaccines 
Prognosis, Prevention, and Complications
  • ↑ risk of postnecrotic cirrhosis secondary to chronic hepatitis
    • may progress to hepatocellular carinoma
 

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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

38%

(23/60)

2

Inactivated vaccine only

17%

(10/60)

3

Toxoid vaccine and live attenuated vaccine

10%

(6/60)

4

Conjugate vaccine and toxoid vaccine

25%

(15/60)

5

Live attenuated vaccine only

5%

(3/60)

M1

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PREFERRED RESPONSE 1

(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

17%

(18/106)

2

Figure B

10%

(11/106)

3

Figure C

10%

(11/106)

4

Figure D

6%

(6/106)

5

Figure E

55%

(58/106)

M1

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PREFERRED RESPONSE 5
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