Important points

1. Alcoholic hepatitis: elevated liver function tests; aspartate aminotransferase levels are more than twice as high as alanine aminotransferase levels in a patient who was just drinking,

2. Hepatitis A: look for outbreaks from food-borne source; no long-term sequelae. Serology: positive IgM antibody to hepatitis A virus during jaundice or shortly thereafter.

3. Hepatitis B: prevention is best treatment (vaccination); acquired through needles, sex, or perinatally. Transfused blood is now screened for hepatitis B, but a history of transfusion years ago is still a risk factor. Use hepatitis B immunoglobulin for exposed neonates and health care workers. Serology: HBsAg-positive with unresolved infection (acute or chronic). HBeAg is a marker for infectivity (HBeAb -positive patients have low likelihood of spreading disease). The first antibody to appear is IgM anti-HBc, which appears during the window phase, when both HBsAg and HBsAb are negative. Positive HBsAb means that the patient is immune (due either to recovery from infection or vaccination) and never appears if the patient develops chronic hepatitis. Sequelae are cirrhosis and hepatocellular cancer (only with chronic infection).

4. Hepatitis C: the new king of chroni c hepatitis; most likely cause of hepati tis after a blood transfusion (used to be hepatitis B before blood was screened). More likely than hepatitis B to progress to chronic hepatitis, cirrhosis, and cancer. Serology : antibody to hepatitis C virus shows immunity. New test for HCV RNA detects virus (blood is now screened).

5. Hepatitis D: seen only in patients with hepatitis B; may become chronic with hepatitis B coinfection. Acquired in same ways as hepatitis B. IgM antibodies to hepatitis D antigen show recent resolution of infection; presence of hepatitis I) antigen means chronicity.

6. Hepatitis K: similar to hepatitis A (food-and water- borne, no chronic state). Often fatal in pregnant women.

1. Drug-induced: look for acetaminophen, isoniazid (other tuberculosis drugs), halothane, carbon tetrachloride, tetracycline. Stop the drug!

8. Reyes syndrome: develops in a child given aspirin for fever.

9, Acute fatty liver of pregnancy: develops in third trimester. Treat with immediate delivery.

10. ischemia/shock: history of shock.

11. Idiopathic autoimmune hepatitis: 20-40-year-old women with anti-smooth muscle or antinuciear antibodies and no risk factors or lab markers of other causes for hepatitis. Treat with steroids.

12. Biliary tract disease: see below; look for markedly elevated alkaline phosphatase.

Jjver disease, chronic: often due to alcohol, hepatitis, and metabolic diseases (hernocbro matosis, Wilson's disease, alpha, antitrypsin deficiency). Stigmata of chronic liver disease include gynecomastia, testicular atrophy, palmar erythema, spider angiomas on skin, and ascites.

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