Case 1: Acute Viral Hepatitis – Hepatocellular Pattern Case 1 Common GP presentation Clinical presentation A 24-year-old male presents with a 5-day history of fever, malaise, nausea, loss of appetite and dark-coloured urine. His family notices yellow discolouration of his eyes for the last 2 days. He denies alcohol consumption or medication use. On examination, he has scleral icterus and mild right upper quadrant tenderness. There is no encephalopathy or ascites. Investigations: Investigation Result Total bilirubin 5.8 mg/dL ALT 1,250 U/L AST 980 U/L ALP 145 U/L GGT 75 U/L Albumin 4.0 g/dL INR 1.1 Questions and answers Q1. What is the most likely diagnosis? Answer: Acute viral hepatitis, with hepatitis A or E being important possibilities in the Indian setting. Q2. What is the pattern of LFT abnormality? Answer: Predominantly hepatocellular injury. Markedly elevated ALT and AST. Mild elevation of ALP. Increased serum bilirubin. Q3. What further investigations would you request? Answer: HBsAg and IgM anti-HBc. IgM anti-HAV. IgM anti-HEV. Anti-HCV, with HCV RNA if indicated. PT/INR. CBC, renal function and electrolytes. Ultrasound abdomen if obstruction or another diagnosis is suspected. Q4. How would you manage this patient in general practice? Answer: Assess hydration and nutritional status. Advise adequate oral fluids and nutrition. Avoid alcohol. Stop unnecessary hepatotoxic medications and supplements. Avoid unnecessary paracetamol and other potentially hepatotoxic drugs. Monitor bilirubin, ALT, AST and INR. Educate regarding hand hygiene and food hygiene, particularly if HAV or HEV is suspected. Q5. What are the red flags requiring urgent hospital referral? Answer: Altered sensorium or hepatic encephalopathy. INR ≥1.5, particularly with acute liver injury. Hypoglycaemia. Bleeding manifestations. Acute kidney injury. Persistent vomiting or inability to maintain hydration. GP learning point: Acute hepatitis with jaundice and coagulopathy or encephalopathy is a medical emergency. Do not manage suspected acute liver failure as an outpatient. Case 2: Obstructive Jaundice – Suspected Choledocholithiasis Case 2 Urgent assessment Clinical presentation A 55-year-old woman presents with yellow discolouration of the eyes for 10 days, itching, dark urine and pale stools. She complains of intermittent right upper abdominal pain, particularly after fatty meals. On examination, she has scleral icterus and mild right upper quadrant tenderness. She is afebrile and haemodynamically stable. Investigations: Investigation Result Total bilirubin 8.5 mg/dL Direct bilirubin 7.2 mg/dL ALT 180 U/L AST 150 U/L ALP 650 U/L GGT 520 U/L Albumin 3.8 g/dL Ultrasound shows gallstones with a dilated common bile duct. Questions and answers Q1. What is the most likely diagnosis? Answer: Extrahepatic obstructive jaundice, most likely due to choledocholithiasis (common bile duct stone). Q2. What is
Case 1: Acute Viral Hepatitis – Hepatocellular Pattern Case 1 Common GP presentation Clinical presentation A 24-year-old male presents with a 5-day history of fever, malaise, nausea, loss of appetite and dark-coloured urine. His family notices yellow discolouration of his eyes for the last 2 days. He denies alcohol consumption or medication use. On examination, he has scleral icterus and mild right upper quadrant tenderness. There is no encephalopathy or ascites. Investigations: Investigation Result Total bilirubin 5.8 mg/dL ALT 1,250 U/L AST 980 U/L ALP 145 U/L GGT 75 U/L Albumin 4.0 g/dL INR 1.1 Questions and answers Q1. What is the most likely diagnosis? Answer: Acute viral hepatitis, with hepatitis A or E being important possibilities in the Indian setting. Q2. What is the pattern of LFT abnormality? Answer: Predominantly hepatocellular injury. Markedly elevated ALT and AST. Mild elevation of ALP. Increased serum bilirubin. Q3. What further investigations would you request? Answer: HBsAg and IgM anti-HBc. IgM anti-HAV. IgM anti-HEV. Anti-HCV, with HCV RNA if indicated. PT/INR. CBC, renal function and electrolytes. Ultrasound abdomen if obstruction or another diagnosis is suspected. Q4. How would you manage this patient in general practice? Answer: Assess hydration and nutritional status. Advise adequate oral fluids and nutrition. Avoid alcohol. Stop unnecessary hepatotoxic medications and supplements. Avoid unnecessary paracetamol and other potentially hepatotoxic drugs. Monitor bilirubin, ALT, AST and INR. Educate regarding hand hygiene and food hygiene, particularly if HAV or HEV is suspected. Q5. What are the red flags requiring urgent hospital referral? Answer: Altered sensorium or hepatic encephalopathy. INR ≥1.5, particularly with acute liver injury. Hypoglycaemia. Bleeding manifestations. Acute kidney injury. Persistent vomiting or inability to maintain hydration. GP learning point: Acute hepatitis with jaundice and coagulopathy or encephalopathy is a medical emergency. Do not manage suspected acute liver failure as an outpatient. Case 2: Obstructive Jaundice – Suspected Choledocholithiasis Case 2 Urgent assessment Clinical presentation A 55-year-old woman presents with yellow discolouration of the eyes for 10 days, itching, dark urine and pale stools. She complains of intermittent right upper abdominal pain, particularly after fatty meals. On examination, she has scleral icterus and mild right upper quadrant tenderness. She is afebrile and haemodynamically stable. Investigations: Investigation Result Total bilirubin 8.5 mg/dL Direct bilirubin 7.2 mg/dL ALT 180 U/L AST 150 U/L ALP 650 U/L GGT 520 U/L Albumin 3.8 g/dL Ultrasound shows gallstones with a dilated common bile duct. Questions and answers Q1. What is the most likely diagnosis? Answer: Extrahepatic obstructive jaundice, most likely due to choledocholithiasis (common bile duct stone). Q2. What is
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This guide covers two critical cases in liver pathology: Acute Viral Hepatitis and Obstructive Jaundice. It outlines the recognition of hepatocellular injury and the need for viral serology, alongside supportive care for liver failure. For obstructive jaundice, it emphasizes identifying conjugated jaundice, interpreting cholestatic liver function tests, and the necessity for duct clearance. Additionally, a GP decision framework is provided to compare liver injury patterns, utilize targeted...