Differentials
Hepatitis B virus (HBV) infection
SIGNS / SYMPTOMS
Often asymptomatic.
History may reveal high-risk behaviour (e.g., illicit intravenous drug use, multiple sexual partners) and absence of chronic heavy alcohol use.
May present as acute hepatitis B infection in adults and sometimes can be fatal from complications such as acute liver failure.
Patients with chronic hepatitis B may develop complications such as cirrhosis, hepatocellular carcinoma, or liver failure.
INVESTIGATIONS
Serum test positive for hepatitis B surface antigen (HBsAg), hepatitis B virus DNA, or anti-hepatitis B core antigen-IgM antibody.
In patients with co-existing ARLD and HBV, but without cirrhosis, alanine aminotransferase (ALT) is usually higher than aspartate aminotransferase (AST).
Hepatitis C virus (HCV) infection
SIGNS / SYMPTOMS
History may reveal high-risk behaviour (e.g., illicit injection drug use) and absence of chronic heavy alcohol use.
Most patients are asymptomatic.
In advanced disease, patients exhibit signs and symptoms related to chronic liver injury from hepatitis C such as jaundice, ascites, spider angiomata, and constitutional complaints.
INVESTIGATIONS
Serum test positive for anti-hepatitis C virus antibody and hepatitis C virus RNA PCR.
Most patients have fluctuating elevation of alanine aminotransferase (ALT) and aspartate aminotransferase (AST).
In patients with co-existing ARLD and HCV but without cirrhosis, ALT is usually higher than AST.
Hepatitis A virus infection
SIGNS / SYMPTOMS
History suggestive of exposure (e.g., use of contaminated food/water, travel to endemic area, men who have sex with men) and absence of binge alcohol use.
Symptomatic patients may present with abrupt-onset fever, abdominal pain, malaise, and jaundice. Common examination findings are hepatomegaly and clinical jaundice.
INVESTIGATIONS
Serum test positive for anti-hepatitis A virus-IgM antibody with marked elevation of serum transaminases.
Cholecystitis
SIGNS / SYMPTOMS
Acute right upper quadrant abdominal pain, with positive Murphy's sign (pain with inspiration beneath palpation at costal margin).
INVESTIGATIONS
Ultrasound of gallbladder is the initial test.
Nuclear medicine hepatobiliary scan may be helpful in cases where diagnosis is unclear.
Hepatic vein thrombosis
SIGNS / SYMPTOMS
Variable chronicity of presentation but classic triad of abdominal pain, hepatomegaly, and ascites is seen.
INVESTIGATIONS
Ultrasound of liver with Doppler study can show obstruction, thrombosis, collaterals, and hyperechoic cords replacing normal venous architecture.
CT abdomen with contrast might be more precise for this diagnosis.
Acute liver failure
SIGNS / SYMPTOMS
Patient with acute symptoms and signs of acute fulminant hepatic deterioration, coagulopathy, encephalopathy, and sometimes cerebral oedema.
Often related to ingestion of hepatotoxic drug (e.g., paracetamol).
INVESTIGATIONS
Severe elevation of aspartate aminotransferase (AST) and alanine aminotransferase (ALT) with prolonged INR and prothrombin time (PT).
Serum ammonia may be dramatically elevated.
Liver biopsy may be diagnostic but is contra-indicated in coagulopathy, unless done by transjugular approach.
Haemochromatosis
SIGNS / SYMPTOMS
Presenting features include fatigue, arthralgias, and diabetes mellitus.
Characteristic skin bronzing may be present.
INVESTIGATIONS
High iron saturation (>45% transferrin saturation) and high ferritin.
Positive haemochromatosis gene mutation.
Liver biopsy shows excessive iron deposition in hepatocytes.
High hepatic iron index.
Wilson's disease
SIGNS / SYMPTOMS
Patients may have neurological manifestations similar to parkinsonism, and psychological manifestations such as psychosis.
Kayser-Fleischer rings may be present on slit-lamp eye examination.
INVESTIGATIONS
Increased urinary copper, decreased serum ceruloplasmin.
Liver biopsy shows excessive copper deposition by copper measurement.
Drug- or toxin-induced hepatitis
SIGNS / SYMPTOMS
History of exposure to hepatotoxic drugs or toxins.
Examination may range from mild and non-specific to fulminant hepatic failure.
INVESTIGATIONS
Liver biopsy may show evidence of hepatocellular injury or cholestatic or mixed pattern of liver injury.
Autoimmune hepatitis
SIGNS / SYMPTOMS
History of immune dysregulation, genetic predisposition, or female sex.
Constitutional symptoms are similar to those of alcohol-related liver injury.
INVESTIGATIONS
There may be positive or elevated anti-nuclear antibody, anti-smooth muscle antibody, or anti-LKM antibody (anti-liver/anti-kidney microsome antibody).
Liver biopsy shows evidence of hepatocellular inflammation with plasma cell infiltrates and interface hepatitis with plasma cell infiltrates.
Wernicke's encephalopathy
SIGNS / SYMPTOMS
Usually presents with abrupt symptoms of confusion, short-term memory loss, eye movement disorders (nystagmus, gaze palsies, and ophthalmoplegia) in a patient with chronic malnutrition.
Low thiamine intake.
INVESTIGATIONS
Clinical diagnosis.
Biliary obstruction
SIGNS / SYMPTOMS
Symptoms associated with biliary obstruction may include right upper quadrant pain, fever/chills, jaundice, pruritus, nausea, and vomiting.
INVESTIGATIONS
Ultrasound abdomen (also CT or MRI of abdomen) may show dilation of biliary tract.
Use of this content is subject to our disclaimer