Skill Checkup: A Man With Itching and Abdominal Pain 

Alastair O'Brien, MBBS, BSc, PhD

Disclosures

March 18, 2021

Viral hepatitis is most commonly caused by hepatitis A virus (HAV), hepatitis B virus (HBV), and hepatitis C virus (HCV). An acute infection with these viruses causes nausea, abdominal pain, fatigue, malaise, and jaundice. Only HBV and HCV can progress to chronic infections that lead to fibrosis, cirrhosis, and hepatocellular carcinoma. This patient is likely to have HCV or HBV infection because intravenous drug use with shared needles is a major risk factor for both these viral infections and, much less commonly, coinfection with both. Tattooing is another potential mode of transmission to which he has been exposed. HAV is less likely because its transmission is mostly orofecal. 

Alcoholic hepatitis is a progressive inflammatory liver disease associated with long-term heavy alcohol consumption. In severe cases it manifests as subacute onset of fever, hepatomegaly, leukocytosis, and signs of liver function failure (ie, jaundice and coagulopathy) and portal hypertension (ie, ascites, hepatic encephalopathy, variceal hemorrhage). This patient states that he is an occasional and not heavy drinker. He is not complaining of symptoms that suggest recent alcohol intoxication. Although this patient presents with slight tenderness over the right upper quadrant, there are no signs of hepatomegaly, splenomegaly, ascites, or encephalopathy. For these reasons, it is unlikely that he is presenting with alcoholic hepatitis. 

The classic presentation of acute cholangitis is jaundice, right upper quadrant abdominal pain, and fever (ie, the Charcot triad). Patients often have chills and rigors associated with the fever. This patient does not complain of fever and has no history of choledocholithiasis (gallstones in the bile ducts) or recent biliary tract manipulation to suggest the diagnosis of cholangitis at this stage.

PSC is a rare progressive disease that presents with recurrent episodes of fatigue, pruritus, and right upper quadrant pain that may resemble viral hepatitis. It may be associated with inflammatory bowel disease. Jaundice, hepatomegaly, and splenomegaly are characteristic findings of advanced disease. Disease progression leads to the appearance of signs of liver failure, including spider angiomata, ascites, and muscle atrophy. The patient’s history of intravenous drug use makes viral hepatitis the most likely diagnosis as compared with PSC. 

A review of the patient’s medical records show positive anti-HCV antibodies and HCV RNA from his previous clinic visit. Other screening tests done at the same visit showed negative immunoassays for HIV-1, HIV-2, HBV, HAV, and TB IGRA assay. In this follow-up visit, viral and hepatitis serologies, full CBC, biochemistry, and renal and liver function tests were ordered and the results showed values within normal ranges except for elevated total bilirubin and alanine aminotransferase (ALT) levels. HCV RNA was found to be positive.

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