Differentials
Acute viral hepatitis
SIGNS / SYMPTOMS
Patients usually appear unwell and present with jaundice, malaise, myalgia, right upper quadrant pain, prodromal constitutional symptoms, nausea, vomiting, and diarrhoea.
INVESTIGATIONS
Markedly elevated liver biochemistry (particularly alanine aminotransferase and bilirubin), positive virology screening.
HELLP syndrome
SIGNS / SYMPTOMS
Symptoms of pre-eclampsia (headache, visual disturbance, epigastric pain, oedema), hyperreflexia, right upper quadrant tenderness, and, in case of severe coagulopathy, bleeding.
INVESTIGATIONS
Haemolysis - identified by elevated LDH and reticulocytes; thrombocytopenia - identified by platelets typically <100 x 10⁹/L, proteinuria, renal impairment (raised creatinine).
Acute fatty liver of pregnancy
SIGNS / SYMPTOMS
Symptoms of pre-eclampsia, often with marked vomiting, polydipsia/polyuria, encephalopathy, coagulopathy, ascites.
INVESTIGATIONS
Hypoglycaemia, raised uric acid, raised ammonia, leucocytosis, renal impairment, coagulopathy, metabolic acidosis.
Absence of ketonuria.
Microvesicular steatosis on liver biopsy.
Polymorphic eruption of pregnancy
SIGNS / SYMPTOMS
Itchy erythematous rash, particularly in striae and over abdomen, with umbilical sparing. Wheals, papules, and plaques may develop.
INVESTIGATIONS
Clinical diagnosis; rarely a skin biopsy may be needed.
Autoimmune liver conditions
SIGNS / SYMPTOMS
Symptoms may be indistinguishable from ICP if first presenting in pregnancy. Primary sclerosing cholangitis may occur in women with inflammatory bowel disease.
INVESTIGATIONS
Raised auto-antibodies, particularly elevated alkaline phosphatase; ultrasound/elastography evidence of hepatic fibrosis.
Drug-induced liver injury
SIGNS / SYMPTOMS
History concurrent with the use of medications associated with increased risk of cholestatic liver injury. Symptoms include right upper quadrant pain, pruritus, generalised malaise, weight loss, fatigue, anorexia, pale stool, dark urine; risk factors for drug-induced liver injury include age, female sex, African-American race, alcohol consumption, pregnancy, and chronic liver disease.[87] A US population study suggested omeprazole, lansoprazole, and amoxicillin to be the most common precipitants.[78] Women may have a history of oral contraceptive-induced cholestasis.
INVESTIGATIONS
Normalisation of hypercholanaemia on ceasing the medication. Occurs more commonly in women with genetic variation in ABCB4.
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