Differentials
Common
Alcoholic liver disease
History
10-12 years of heavy alcohol consumption (>40-80 g/day for men and 20-40 g/day for women), abdominal pain, pruritus, generalised malaise, weight loss, fatigue, anorexia, cachexia, pale stool, dark urine, melaena, or haematemesis
Exam
generalised wasting, gynaecomastia, altered mental status, asterixis or altered deep tendon reflexes, ecchymosis or petechiae, spider angioma, thenar eminence loss, palmar erythema, caput medusae, ascites, hepatosplenomegaly or small liver, pleural effusion, right heart failure, positive rectal examination (blood)
1st investigation
- serum liver function tests:
aspartate aminotransferase (AST) and alanine aminotransferase (ALT) rarely >200 U/L; raised serum bilirubin; low albumin
- AST:ALT ratio:
more than 2:1 in alcoholic liver disease, reflecting lower ALT activity in these patients[100]
More - prothrombin time (PT)/INR:
elevated
More - FBC:
low platelet count; high WBC count
More - urea:
elevated
More - CAGE score:
>2
More - Alcohol Use Disorders Identification Test (AUDIT)-C score:
>5
More - abdominal ultrasound:
usually hyperechoic due to fatty infiltration, may describe mixed echogenicity; possibly nodular liver in cirrhotic patients with evidence of portal hypertension, splenomegaly, and ascites
More
Choledocholithiasis
History
right upper quadrant (RUQ) pain, aggravated by meals, fever
Exam
RUQ abdominal tenderness, fever (in cholecystitis)
1st investigation
- serum liver function tests:
high direct bilirubin, gamma glutamyl transferase, and alkaline phosphatase
- prothrombin time/INR:
usually normal or mildly increased due to reduced vitamin K absorption
- FBC:
elevated white blood cell count
- abdominal ultrasound:
intra- and extrahepatic biliary tree dilatation with/without stone(s) in the common bile duct
More
Other investigations
- serum cholesterol:
may be increased
- magnetic resonance cholangiopancreatography (MRCP):
stone(s) in the bile duct
More - endoscopic ultrasound:
stone(s) in the bile duct
More - CT:
partially calcified biliary calculi; complications such as cholangitis, cholecystitis, pancreatitis
More - endoscopic retrograde cholangiopancreatography (ERCP):
stone(s) in the bile duct
More
Hepatitis A
History
may be history of risk factors (e.g., travel to endemic part of the world, close contact with known infected person, known food-borne outbreak), anorexia, nausea, vomiting, diarrhoea, abdominal pain, weight loss
Exam
abdominal tenderness, tender hepatosplenomegaly, lymphadenopathy, jaundice; fulminant infection: worsening jaundice, ascites, signs of encephalopathy (e.g., memory, attention, and concentration deficits, confusion, asterixis, nystagmus, clonus, rigidity, coma)
1st investigation
- serum liver function tests:
high direct bilirubin, aspartate aminotransferase, alanine aminotransferase, alkaline phosphatase, and gamma glutamyl transferase
- serum IgM anti-hepatitis A virus:
positive
- prothrombin time/INR:
may be increased
- FBC:
low or normal platelet count
Other investigations
Hepatitis B
History
may be history of risk factor (e.g., travel to endemic part of the world, high-risk sexual history, intravenous drug use), may have minimal or no symptoms, may have lethargy, nausea, vomiting, abdominal pain; acute presentation (uncommon): worsening jaundice and lethargy, confusion; chronic infection with late complications: pruritus, abdominal swelling, haematemesis, melaena, confusion, lethargy, weight loss, weakness, bruising
Exam
acute infection: usually normal, but may have jaundice, tender hepatomegaly, and if severe: signs of encephalopathy (e.g., memory, attention, and concentration deficits, confusion, asterixis, nystagmus, clonus, rigidity, coma); chronic infection: may have jaundice, muscle wasting, gynaecomastia, palmar erythema, spider angiomata, petechiae, ascites, distended abdominal veins, hepatosplenomegaly, signs of encephalopathy
1st investigation
- serum liver function tests:
high direct bilirubin, aspartate aminotransferase, alanine aminotransferase, alkaline phosphatase, and gamma glutamyl transferase
- prothrombin time/INR:
may be increased
- FBC:
low or normal platelet count
- serum hepatitis B surface antigen (HBsAg):
positive - appears 2-10 weeks after exposure to hepatitis B virus (HBV); in self-limiting acute HBV infection, HBsAg usually becomes undetectable after 4-6 months of infection; persistence of HBsAg for >6 months implies chronic HBV infection[101]
- serum anti-hepatitis B core antigen (anti-HBc) IgM:
positive - appears within weeks of acute infection and remains detectable for 4-8 months; during the window period (several weeks to months) after the disappearance of HBsAg and before the appearance of anti-HBs, detection of IgM anti-HBc may be the only way to make the diagnosis of acute HBV infection
More - serum hepatitis B e antigen (HBeAg):
positive
More - hepatitis B virus DNA:
elevated
Other investigations
- abdominal ultrasound:
cirrhosis; hepatocellular carcinoma
Hepatitis C
History
may be history of risk factors, (e.g., intravenous drug use, blood transfusion before 1992 in the US, high-risk sexual history); acute infection: usually asymptomatic, may be fatigue, jaundice; chronic infection: may be asymptomatic, but possible symptoms related to cirrhosis and its complications, such as pruritus, abdominal swelling, haematemesis, melaena, confusion, lethargy, weight loss, weakness, bruising
Exam
early disease: normal examination; late disease with chronic infection: may be jaundice, muscle wasting, gynaecomastia, palmar erythema, spider angiomata, petechiae, ascites, distended abdominal veins, hepatosplenomegaly, signs of encephalopathy (e.g., memory, attention, and concentration deficits, confusion, asterixis, nystagmus, clonus, rigidity, coma)
1st investigation
- serum liver function tests:
high direct bilirubin, aspartate aminotransferase, alanine aminotransferase, alkaline phosphatase, and gamma glutamyl transferase
- prothrombin time/INR:
may be increased
- FBC:
low or normal platelet count
- anti-hepatitis C antibody:
positive; negative antibodies do not rule out hepatitis C virus infection in acute infection or in severely immunocompromised patients
- nucleic acid amplification test:
positive; detects viraemia in early infection
Other investigations
- abdominal ultrasound:
may show cirrhosis and evidence of portal hypertension
Drug-induced liver injury
History
over 100 drugs implicated, 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[27]
Exam
tender hepatosplenomegaly, lymphadenopathy
1st investigation
- serum liver function tests:
high total bilirubin, alanine aminotransferase, and aspartate aminotransferase
- prothrombin time/INR:
increased
- FBC:
low or normal platelet count, high white blood cell count
- abdominal ultrasound:
non-specific findings
- serum paracetamol:
elevated if overdose, may be normal in staggered overdose
Other investigations
Ascending cholangitis
History
chills, pain, pale stools, dark urine, pruritus, generalised malaise, weight loss, fatigue, anorexia
Exam
Charcot's triad: fever, right upper quadrant tenderness, jaundice
1st investigation
- serum liver function tests:
high direct bilirubin, gamma glutamyl transferase, and alkaline phosphatase
- prothrombin time/INR:
may be increased
- FBC:
elevated white blood cell count
- CRP:
elevated
- abdominal ultrasound:
biliary dilatation and stone(s) in bile duct
Other investigations
- magnetic resonance cholangiopancreatography:
stone(s) in the bile duct
- endoscopic ultrasound:
stone(s) in the bile duct
- endoscopic retrograde cholangiopancreatography:
bile duct obstruction; pus draining from the biliary tree
More
Pancreatic carcinoma
History
often asymptomatic until late disease, depression, weight loss, early satiety, new-onset diabetes, abdominal pain, pruritus, generalised malaise, fatigue, anorexia, pale stool, dark urine
Exam
positive Courvoisier's law/sign, palpable gallbladder, ill-appearing, cachectic
1st investigation
- serum liver function tests:
high direct bilirubin, alkaline phosphatase, and gamma glutamyl transferase
- prothrombin time/INR:
may be increased
- FBC:
low or normal platelet count, Hb, and haematocrit
- abdominal ultrasound:
pancreatic mass and dilated common bile duct ± pancreatic duct dilatation
Other investigations
- CT:
pancreatic mass and dilated bile duct ± pancreatic duct dilatation
More - fluorodeoxyglucose-positron emission tomography/CT (FDG‑PET/CT):
increased FDG activity of pancreatic lesion
More - linear endoscopic ultrasound:
pancreatic mass
More - endoscopic retrograde cholangiopancreatography (ERCP):
bile duct and pancreatic duct strictures
More
Liver metastases
History
history of malignancy (colorectal, breast, lung, lymphoma); weight loss, fatigue, abdominal swelling
Exam
jaundice, hepatomegaly, ascites, cachexia, signs of other malignancies
1st investigation
- serum liver function tests:
raised transaminases suggest hepatocyte destruction; raised alkaline phosphatase and gamma glutamyl transferase suggest cholestasis caused by external compression of the biliary tree
- prothrombin time/INR:
may be increased
- abdominal ultrasound:
identifies metastases and biliary duct dilatation
Other investigations
- CT chest, abdomen, pelvis:
identifies extent of intra-abdominal tumour, and may identify primary malignancy if not already known
Haemolytic anaemia
History
fever or chills, family history of haemolytic disorders, abdominal pain, pruritus, generalised malaise, weight loss, fatigue, anorexia, dark urine
Exam
new onset of pallor, splenomegaly
1st investigation
- serum liver function tests:
high indirect bilirubin with normal or minimally elevated aspartate aminotransferase, alanine aminotransferase, alkaline phosphatase
- FBC:
low Hb
- direct/indirect bilirubin:
elevated indirect bilirubin
- abdominal ultrasound:
non-specific
Other investigations
Decompensated cirrhosis
History
known chronic liver disease; recent infection may precipitate decompensation; may report haematemesis or melaena
Exam
jaundice, ascites; stigmata of chronic liver disease including generalised wasting, gynaecomastia, ecchymosis or petechiae, spider angioma, thenar eminence loss, palmar erythema, caput medusae; signs of hepatic encephalopathy including shortened attention span, confusion, impaired addition or subtraction, disorientation in time and/or space, dyspraxia, asterixis, hyperreflexia, nystagmus, clonus, and rigidity; melaena
1st investigation
- serum liver function tests:
elevated bilirubin; variable derangement of alanine aminotransferase, aspartate aminotransferase and/or alkaline phosphatase
- prothrombin time/INR:
elevated (>1.5)
- FBC:
thrombocytopenia
- urea:
elevated following an upper gastrointestinal bleed
- CRP:
elevated in infection
- full metabolic profile:
hyponatraemia; abnormal calcium, phosphorus, or magnesium levels; hypoglycaemia
- culture of ascitic fluid:
may be positive
More - blood culture:
may be positive
More - chest x-ray:
may show pneumonia or pleural effusion
More - urine culture:
may be positive
More - ultrasound:
ascites, splenomegaly
Acute liver failure
History
abdominal discomfort, nausea, vomiting, anorexia; relatives may report personality changes; may be history of paracetamol overdose or other drug ingestion, risk factors for viral hepatitis, history of shock (predisposes to ischaemic hepatitis); may be past medical history of hypercoagulable state (Budd-Chiari syndrome); may be a family history of Wilson's disease
Exam
hepatomegaly and right upper quadrant tenderness may be present; signs of hepatic encephalopathy include shortened attention span, confusion, impaired addition or subtraction, disorientation in time and/or space, dyspraxia, asterixis, hyperreflexia, nystagmus, clonus, and rigidity; stigmata of chronic liver disease are absent
1st investigation
- prothrombin time/INR:
elevated (>1.5)
- serum liver function tests:
hyperbilirubinaemia, elevated liver enzymes
- basic metabolic panel:
may be elevated urea and creatinine, metabolic derangements
More - FBC:
leukocytosis, anaemia, thrombocytopenia
More - arterial blood gas:
metabolic acidosis
More - paracetamol level:
may be elevated; however, low paracetamol levels do not exclude paracetamol hepatotoxicity
More
Other investigations
- viral hepatitis serologies:
may be positive
More - autoimmune hepatitis markers:
may be positive
More - pregnancy test:
may be positive
More - chest x-ray:
possible aspiration pneumonia
More - abdominal ultrasound with Doppler:
hepatic vessel thrombosis, loss of hepatic venous signal, and reverse flow in the portal vein in Budd-Chiari syndrome; hepatomegaly, splenomegaly, hepatic surface nodularity
- work-up for Wilson's disease:
low serum ceruloplasmin; elevated serum copper; elevated 24-hour urinary copper excretion, Kayser-Fleischer rings present on slit-lamp ophthalmological examination
More - CT scan of head:
cerebral oedema, haemorrhage
More
Acute-on-chronic liver failure
History
history of acute hepatic insult in a patient with chronic liver disease (e.g., sepsis, active alcohol misuse); jaundice, ascites, abdominal discomfort, nausea, vomiting, anorexia; relatives may report personality changes; may be signs of variceal bleeding (e.g., haematemesis, melaena)
Exam
jaundice, ascites; stigmata of chronic liver disease including generalised wasting, gynaecomastia, ecchymosis or petechiae, spider angioma, thenar eminence loss, palmar erythema, caput medusae; signs of hepatic encephalopathy including shortened attention span, confusion, impaired addition or subtraction, disorientation in time and/or space, dyspraxia, asterixis, hyperreflexia, nystagmus, clonus, and rigidity
1st investigation
- prothrombin time/INR:
elevated (>1.5)
- serum liver function tests:
hyperbilirubinaemia, elevated liver enzymes
- FBC:
elevated white cell count
- CRP:
elevated
- serum electrolytes, urea, and creatinine:
elevated urea and creatinine; hyponatraemia
Uncommon
Gilbert's syndrome
History
young adult, more common in males, often asymptomatic or non-specific symptoms (abdominal cramps, fatigue, malaise)
Exam
normal other than icterus
1st investigation
- serum liver function tests:
high indirect bilirubin; normal alkaline phosphatase
More - prothrombin time/INR:
normal
- FBC:
normal
Other investigations
- blood smear:
normal
- reticulocyte count:
normal
Hepatitis E
History
may be history of risk factors (e.g., travel to Southeast Asia, northern and central Africa, India, and Central America), exposure to pigs or undercooked pork; more common in middle-aged/older men; anorexia, nausea and vomiting, diarrhoea, abdominal pain, pruritus, myalgia, neurological symptoms (5% of patients); pregnancy is associated with more florid disease; patients with pre-existing liver disease have a high risk of decompensation and a 70% mortality
Exam
may be normal; abdominal tenderness, tender hepatosplenomegaly, lymphadenopathy, jaundice, ascites, signs of encephalopathy (e.g., memory, attention, and concentration deficits, confusion, asterixis, nystagmus, clonus, rigidity, coma)
1st investigation
- serum liver function tests:
high direct bilirubin, aspartate aminotransferase, alanine aminotransferase, alkaline phosphatase, and gamma glutamyl transferase
- prothrombin time/INR:
may be increased
- abdominal ultrasound:
nonspecific
Other investigations
- serum anti-hepatitis E virus IgM antibodies:
positive
More - hepatitis E virus polymerase chain reaction:
positive
Hepatitis D
History
may be history of risk factors (e.g., infection with hepatitis B virus, high-risk sexual history, intravenous drug use), minimal or no symptoms; acute presentation (uncommon): jaundice, lethargy, confusion; chronic infection with late complications: itching, abdominal swelling, haematemesis, melaena, confusion, lethargy, weight loss, weakness, bruising
Exam
usually normal, but if severe acute infection may be jaundice, tender hepatomegaly, signs of encephalopathy (e.g., memory, attention, and concentration deficits, confusion, asterixis, nystagmus, clonus, rigidity, coma); chronic, late infection: may be jaundice, muscle wasting, gynaecomastia, palmar erythema, spider angiomata, petechiae, ascites, distended abdominal veins, hepatosplenomegaly, signs of encephalopathy
1st investigation
- serum liver function tests:
high direct bilirubin, aspartate aminotransferase, alanine aminotransferase, alkaline phosphatase, and gamma glutamyl transferase
- prothrombin time/INR:
may be increased
- FBC:
low or normal platelet count
- abdominal ultrasound:
nonspecific
Other investigations
- serum IgM anti-hepatitis D virus:
positive
- serum total (IgM and IgG) anti-hepatitis D virus antibodies:
positive
- serum hepatitis B surface antigen (HBsAg):
positive
- serum anti-hepatitis B core antigen antibody:
positive
- serum hepatitis B e antigen (HBeAg):
positive
More
Leptospirosis
History
history of direct or indirect contact with urine of infected animals or contaminated water; acute phase symptoms include fever, rigors, headache, calf muscle tenderness, abdominal pain, diarrhoea, nausea vomiting, asthenia, anorexia, and photophobia; immune phase symptoms occur 5 to 7 days later and include severe eye pain, headache, photophobia, pulmonary symptoms (cough, dyspnoea, chest pain, haemoptysis), palpitations, muscle tenderness, and mental status changes
Exam
acute/initial phase: high fever (up to 40℃ [104°F]), rigors, hypotension, tachycardia, lymphadenopathy, calf muscle tenderness; immune phase: consolidation secondary to pulmonary haemorrhage, crackles and wheeze secondary to pulmonary oedema; arrhythmias, nuchal rigidity, delirium, weakness and paralysis, mental status changes, focal neurological deficit; both phases: hepatosplenomegaly, abdominal tenderness, jaundice, bilateral conjunctival suffusion
1st investigation
- FBC:
high WBC count; low platelet count; anaemia
More - serum liver function tests:
markedly elevated conjugated bilirubin levels, elevated aminotransferases or alkaline phosphatase
- CRP:
elevated
- serum electrolytes, urea, and creatinine:
elevated urea and creatinine; hypokalaemia
- blood culture:
positive after 1 week to 4 months
More - enzyme-linked immunosorbent assay (ELISA):
positive during immune phase
More - urinalysis:
mild proteinuria; pyuria; haematuria; hyaline or granular casts
Immunoglobulin G4 (IgG4) cholangiopathy
History
epigastric and abdominal pain, jaundice, weight loss; typically men aged 50-60 years; may give history of new onset diabetes mellitus or diarrhoea associated with pancreatic insufficiency
Exam
epigastric tenderness, jaundice; may have lymphadenopathy, bibasal crepitation related to multisystemic manifestation
1st investigation
- serum liver function tests:
high direct bilirubin, gamma glutamyl transferase, and alkaline phosphatase; mildly elevated aspartate aminotransferase and alanine aminotransferase
- serum IgG4 level:
≥1.35 g/L (≥135 mg/dL)
- abdominal ultrasound or CT scan:
biliary dilatation with simultaneous intra- and extrahepatic duct dilatation
Other investigations
- magnetic resonance cholangiopancreatography:
simultaneous strictures and radiological evidence of associated pancreatitis
- endoscopic ultrasound:
useful in obtaining tissue for histology; may reveal vascular involvement of the splenic, portal, and superior mesenteric veins
- endoscopic retrograde cholangiopancreatography (ERCP):
bile duct obstruction; pus draining from the biliary tree
More
Cholangiocarcinoma
History
pruritus, generalised malaise, weight loss, fatigue, anorexia, pale stool, dark urine
Exam
usually normal; cachectic
1st investigation
- serum liver function tests:
high direct bilirubin, alkaline phosphatase, and gamma glutamyl transferase
- prothrombin time/INR:
may be increased
- FBC:
low or normal platelet count, Hb, and haematocrit
- abdominal ultrasound:
diagnosis suspected when intrahepatic ducts are dilated; intrahepatic cholangiocarcinoma may be seen as a mass lesion
- abdominal CT or MRI:
intrahepatic mass lesion, dilated intrahepatic ducts, and localised lymphadenopathy may be seen
More
Hepatocellular carcinoma (HCC)
History
history of cirrhosis or chronic hepatitis B infection, jaundice, weight loss, right upper quadrant pain, abdominal distension
Exam
jaundice, hepatomegaly, cachexia, splenomegaly
1st investigation
- serum liver function tests:
elevated aminotransferases, alkaline phosphatase, and bilirubin; low albumin
- FBC:
low platelet count is indicative of portal hypertension resulting from cirrhosis
- prothrombin time/INR:
normal or elevated
- alpha fetoprotein (AFP):
AFP level is elevated in 60% of patients with HCC, typically those with the most advanced disease; mild elevations may occur in patients with chronic hepatitis but not HCC[105]
- ultrasound of liver:
poorly defined margins and coarse, irregular internal echoes
Other investigations
- anti-hepatitis B core antigen (HBc) IgG:
positive in chronic infection
- anti-hepatitis C virus IgG:
positive in chronic infection
- CT scan of abdomen with contrast:
hypervascular pattern; highly specific for HCC
Post-operative stricture
History
gallbladder or bile duct surgery, abdominal pain, pruritus, fatigue, anorexia, pale stool, dark urine
Exam
often normal examination
1st investigation
- serum liver function tests:
high direct bilirubin, alkaline phosphatase, and gamma glutamyl transferase
- prothrombin time/INR:
may be increased
- FBC:
low or normal platelet count, Hb, and haematocrit
- abdominal ultrasound:
non-specific
- magnetic resonance cholangiopancreatography:
biliary stricture
Other investigations
- endoscopic retrograde cholangiopancreatography (ERCP):
biliary stricture
More
Primary sclerosing cholangitis
History
often asymptomatic, history of ulcerative colitis or Crohn's disease may be present; chills, night sweats, abdominal pain suggest infection; pruritus, generalised malaise, weight loss, fatigue, anorexia, pale stool, dark urine
Exam
usually normal, skin excoriations may be present
1st investigation
Other investigations
- endoscopic retrograde cholangiopancreatography (ERCP):
biliary strictures
More
Primary biliary cholangitis
History
female, pruritus, fatigue, generalised malaise, weight loss, anorexia, pale stool, dark urine, keratoconjunctivitis, xerostomia
Exam
xanthelasma, hepatosplenomegaly, right upper quadrant pain, fatty subcutaneous deposits
1st investigation
Other investigations
- magnetic resonance cholangiopancreatography (MRCP):
normal
More
Wilson's disease
History
family history may be positive; symptoms emerging in childhood, adolescence, or early adulthood; tremor, slurred speech, abdominal pain, pruritus, generalised malaise, weakness, weight loss, anorexia, pale stools, dark urine, irritability, depression, easy bruising
Exam
Kayser-Fleischer rings, parkinsonian-like tremor, rigidity, clumsy gait, poor balance, impaired coordination, abnormal postures, repetitive movements, bradykinesia (tongue, lips, and jaw), dysarthria, dysphonia (hoarse voice), inappropriate and uncontrollable grinning (risus sardonicus), drooling, hypermelanotic pigmentation, bruises, signs of dementia and/or psychosis, jaundice, hepatosplenomegaly
1st investigation
- serum liver tests:
may be normal, elevated aspartate aminotransferase, alanine aminotransferase, direct bilirubin; alkaline phosphatase normal or below normal; alkaline phosphatase (ALP): bilirubin ratio of <4 has a high sensitivity and specificity for diagnosing acute liver failure secondary to Wilson's disease[104]
- prothrombin time/INR:
may be increased
- FBC:
may be normal; cirrhosis: low platelet count
- abdominal ultrasound:
non-specific
- serum ceruloplasmin:
decreased
More - 24-hour urinary copper excretion:
elevated
More - slit-lamp ophthalmological examination:
Kayser-Fleischer rings present in Wilson disease
Hereditary haemochromatosis
History
asymptomatic or found after screening in patients with a positive family history; jaundice occurs in decompensated disease with established cirrhosis; rarely, patients present with symptoms of diabetes
Exam
usually normal; gynaecomastia, ascites, altered mental state, cachectic; in decompensated disease signs of chronic liver disease plus associated arthropathy
1st investigation
- serum liver function tests:
high direct bilirubin, alkaline phosphatase, and gamma glutamyl transferase
- prothrombin time/INR:
may be increased
- FBC:
low or normal platelet count
- serum iron, serum total iron binding capacity (TIBC), serum ferritin:
high iron, low TIBC, high ferritin
- serum transferrin saturation:
>45%
Other investigations
- genetic test for haemochromatosis:
positive for haemochromatosis gene mutation
- liver biopsy:
increased iron stores
More
Alpha-1 antitrypsin deficiency
History
family history of liver disease, abdominal pain, pruritus, generalised malaise, weight loss, fatigue, anorexia, emphysema
Exam
jaundice, asterixis, hepatomegaly, ascites; wheeze and/or chest hyper-inflation if emphysema is present
1st investigation
- serum liver function tests:
high direct bilirubin, aspartate aminotransferase, and alanine aminotransferase and alkaline phosphatase
- prothrombin time/INR:
may be increased
- FBC:
low or normal platelet count
- alpha-1 antitrypsin (AAT) serum level:
<20 micromol/L (<108.7 mg/dL)
Parasitic infections
History
travel to endemic areas, abdominal pain, pruritus, generalised malaise, weight loss, fatigue, anorexia, pale stool, dark urine
Exam
cachexia, muscle wasting, tender abdomen, hepatomegaly
1st investigation
- stool for ova and parasites:
positive
More - serum liver function tests:
high direct bilirubin, alkaline phosphatase, and gamma glutamyl transferase
- prothrombin time/international normalised ratio:
may be increased
- FBC:
low or normal platelet count
- CRP:
may be elevated
- abdominal ultrasound:
Ascaris lumbricoides: long, linear, echogenic structures; 4 lines sign or non-shadowing echogenic strips with central tube; Entamoeba histolytica liver abscess
- Giemsa-stained thick and thin blood smears:
Plasmodium falciparum trophozoites in infected erythrocytes
Other investigations
- cholangiography:
Clonorchis sinensis: multiple saccular dilatations of intrahepatic bile ducts; periportal fibrosis
- magnetic resonance cholangiopancreatography:
parasite visualised in the bile duct
- endoscopic retrograde cholangiopancreatography:
parasite visualised in the bile duct
More
AIDS cholangiopathy
History
abdominal pain, pruritus, generalised malaise, weight loss, fatigue, anorexia, pale stool, dark urine, high-risk sexual activity (many partners, unprotected intercourse, intercourse with HIV-infected), HIV-positive, diarrhoea
Exam
cachexia, right upper quadrant and epigastric pain, fever
1st investigation
- serum liver function tests:
high direct bilirubin, alkaline phosphatase, and gamma glutamyl transferase
- prothrombin time/INR:
may be increased
- FBC:
low or normal platelet count
- abdominal ultrasound:
non-specific
Other investigations
- endoscopic retrograde cholangiopancreatography:
papillary stenosis and/or biliary strictures
Heart failure
History
dyspnoea, paroxysmal nocturnal dyspnoea, orthopnoea, ascites; may be history of chest pain associated with myocardial infarction in ischaemic hepatitis; risk factors for heart failure (e.g., previous myocardial infarction, diabetes mellitus, hypertension, valvular heart disease, atrial fibrillation)
Exam
jaundice, hepatomegaly, ascites, hepatojugular reflux, cardiomegaly, elevated jugular venous pressure, third heart sound gallop rhythm, rales, signs of pleural effusion, peripheral oedema
1st investigation
- serum liver function tests:
elevated bilirubin, alanine aminotransferase (ALT), and aspartate aminotransferase
More - serum troponin:
may be elevated
- electrocardiogram:
may show atrial fibrillation or left bundle branch block
- chest x-ray:
may show increased cardio-thoracic ratio and/or bilateral pleural effusions
- echocardiogram:
left ventricular impairment; may show valvular heart disease
Other investigations
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