Hep, Hep, Hepatitis!

65 year old female with a history of steroid dependent pemphigus vulgaris would like a second opinion on treatment options. Upon review of her medical records, the rheumatologist discovers she has a history of positive hepatitis B core antibody and refers her to hepatology clinic for further workup. 

Her rheumatologist would like to start her on rituximab and would like to know if this can be initiated immediately. What do you do next?

Deciphering the code of iron overload

A 60 year old male with a history of HTN, arthritis, diabetes and stroke presents to hepatology clinic for evaluation of fatigue and a positive hepatitis C antibody. Additional lab work reveals a total bilirubin of 1.0 mg/dL, alkaline phosphatase of 90 U/L, AST of 100 U/L, ALT of 80 U/L, INR 1.2, platelet count of 160, hemoglobin of 13 g/dL. ASMA, ANA, Hep B serologies were negative. Hepatitis C viral load could not be processed in the lab due to an ‘inadequate sample.’ Iron studies were obtained which revealed a ferritin of 1481 ng/mL, iron of 184 ug/dL, and transferrin saturation of 60.5%.  Patient denies alcohol use, denies new medications.

On physical exam, there is no evidence of volume overload or hepatosplenomegaly. His second and third metacarpophalangeal joints appear swollen and enlarged bilaterally. No skin lesions or hyperpigmentation noted.

Family history is notable for his sister who was recently found to have abnormal liver chemistries, which the patient thinks is also due to Hepatitis C

Hepatic Abscesses: Where Hepatology meets Infectious Disease

A 63-year-old female presents to the ER with right upper quadrant pain and jaundice. History is notable for a hepatic abscess thought to be secondary to acute cholecystitis three months ago at an outside hospital. At that time, AST was 300 U/L, ALT 200 U/L, alkaline phosphatase 113 U/L, and total bilirubin of 3.5 mg/dL. Hospital course was complicated by Escherichia coli bacteremia. The hepatic abscess was ultimately drained and culture results were positive for Klebsiella pneumoniae and Escherichia coli. The patient was discharged on antibiotics and told to follow up with surgeons for a cholecystectomy. The patient now re-presents with pain and jaundice. On exam, the patient is febrile to 38.9°C, BP 120/60, heart rate 96 bpm. Labs are now significant for conjugated hyperbilirubinemia of 8.8 mg/dL, alkaline phosphatase of 1844 U/L, AST 418 U/L, and ALT 215 U/L. No leukocytosis or eosinophilia is present. An ultrasound in the ER reveals signs of chronic cholecystitis and a large fluid collection in the right lobe of the liver.

Pregnancy, pruritus and pain, oh my! A case-based approach to abnormal liver chemistries in pregnancy

25-year-old female with hyperthyroidism who is 30 weeks pregnant initially presented with costovertebral tenderness, pelvic pain and nausea. Pain resolved after passing a kidney stone, but  initial labs are concerning for abnormal liver chemistries with AST of 118 U/L, ALT of 162 U/L, alkaline phosphatase of 200 U/L, Total Bilirubin of 2.0 mg/dL and INR of 1.0.  What is the next best step?

Helpful Hepatic Hydrothorax Highlights: A Case Taken from the World of Twitter

75-year-old male presents with diuretic refractory hepatic hydrothorax. No overt hepatic encephalopathy but family has noted some episodes of intermittent confusion. He is independent in his activities of daily living. MELD is less than 10.  No history of congestive heart failure, chronic kidney disease or hyponatremia. What do you recommend?