Select an option to reveal the explanation.
Explanation of Answer
Best answer and reason
Correct answer: Acute hepatitis
A fortnight of malaise and joint pains followed by jaundice, dark urine, pale stools and a tender, smoothly enlarged liver describes inflammation of the liver parenchyma, most often viral, rather than a stone or an infected duct.
The timeline does most of the work. A flu-like prodrome that precedes jaundice points to a systemic infection of the liver, not a biliary emergency, which starts abruptly with pain. The liver itself is the tender organ: an inflamed, swollen liver stretches its capsule and aches under the right costal margin. Dark urine means conjugated bilirubin is reaching the urine, and pale stools mean little is reaching the gut.
- Prodrome then jaundice: malaise and joint pains for days to weeks before the patient turns yellow.
- Dark urine and pale stools: conjugated hyperbilirubinaemia from swollen, poorly draining liver cells.
- Tender, mildly enlarged liver: parenchymal inflammation, with no fever and rigors to suggest cholangitis.
Why the other options are wrong
Ascending cholangitis
Cholangitis gives Charcot's triad of right upper quadrant pain, fever with rigors and jaundice from an obstructed, infected duct. It is abrupt and septic, not preceded by two weeks of malaise and joint pains.
Acute cholecystitis
Cholecystitis causes constant right upper quadrant pain, fever and a positive Murphy's sign; jaundice is unusual because the common bile duct stays patent, and the liver is not diffusely enlarged.
Liver failure
Acute liver failure is a possible complication, recognised by encephalopathy and coagulopathy. This man has jaundice and discomfort only, with no confusion or bleeding described.
Biliary colic
Biliary colic is episodic right upper quadrant pain after meals that settles within hours. It does not cause jaundice, a viral prodrome or tender hepatomegaly.
Acute pancreatitis
Pancreatitis presents with sudden severe epigastric pain radiating to the back and vomiting, with raised lipase or amylase, rather than gradual jaundice after a prodrome.
Primary biliary cirrhosis
Now called primary biliary cholangitis, it is a chronic cholestatic disease, mostly of middle-aged women, with fatigue, itch and a positive antimitochondrial antibody, not a two-week illness in a young man.
Gilbert syndrome
Gilbert syndrome causes mild unconjugated jaundice during fasting or illness. Urine and stool colour stay normal, the liver is normal and there is no prodrome.
Exam takeaway
- The history before the jaundice and the colour of urine and stool sort most cases.
- Prodrome, then jaundice with a tender liver: acute hepatitis.
- Pain, fever with rigors and jaundice: cholangitis until proven otherwise.
- Hepatitic pattern: predominantly raised ALT and AST; cholestatic pattern is predominantly raised ALP and GGT.
- ALT above 1000 U/L: think of hepatitis A and E and cytomegalovirus, as well as B and C.
- Confusion or bruising: suggests acute liver failure and needs same-day specialist input.
Learn the Condition
Acute viral hepatitis in a young adult
Acute viral hepatitis in a young adult
Definition
Acute hepatitis is inflammation of the liver over days to weeks, recognised by a predominantly raised ALT and AST. Viruses are the commonest cause in a previously well young adult, but drugs, alcohol and autoimmune disease produce the same picture. Most viral cases resolve; a minority progress to acute liver failure, and hepatitis B and C can become chronic.
Causes
| Virus | Spread | Incubation | Course |
|---|---|---|---|
| Hepatitis A | Faecal-oral: person to person, contaminated food or drink | Usually 28 to 30 days (15 to 50) | No chronic state; severity rises with age |
| Hepatitis B | Sexual intercourse, blood exposure, perinatal | 40 to 160 days | Chronic in 5 per cent or fewer after adult infection |
| Hepatitis C | Blood exposure | Not the usual acute jaundiced picture | Test antibody, then PCR if positive |
| Hepatitis E and CMV | Consider when ALT is very high | Not tabulated here | Tested when ALT exceeds 1000 U/L |
Non-viral causes produce the same hepatitic pattern and must be excluded in every case: paracetamol and other drugs (including over-the-counter and herbal products), alcohol-related hepatitis, autoimmune hepatitis with a raised IgG, and ischaemic hepatitis after a period of hypotension. A careful drug and exposure history often gives the answer before any serology returns.
Differential diagnosis
| Type of jaundice | Urine | Stools | Examples |
|---|---|---|---|
| Unconjugated (prehepatic) | Normal colour | Normal | Haemolysis, Gilbert syndrome |
| Hepatocellular | Dark | Often pale | Viral, drug or alcohol hepatitis |
| Obstructive (posthepatic) | Dark | Pale | Stone in the common bile duct, pancreatic cancer |
Hepatitis and obstruction both give dark urine and pale stools, so the history and the enzyme pattern separate them: a hepatitic rise in ALT and AST, or a cholestatic rise in ALP and GGT with a dilated duct on ultrasound.
Clinical features
- Prodrome: malaise, anorexia, nausea and joint pains, sometimes low-grade fever.
- Icteric phase: jaundice, dark urine and pale stools.
- Examination: tender, smoothly enlarged liver.
- Jaundice frequency: 70 to 80 per cent of adults with hepatitis A and 30 to 50 per cent with hepatitis B.
- Warning signs: drowsiness, confusion and bruising suggest acute liver failure.
Investigation
- Liver blood tests: a hepatitic pattern with a raised bilirubin.
- Synthetic function: prothrombin time or INR and albumin.
- Viral serology: hepatitis B surface antigen and hepatitis C antibody, adding hepatitis A, E and CMV when ALT exceeds 1000 U/L.
- Other causes: paracetamol level if relevant, autoantibodies, immunoglobulins and an ultrasound to exclude duct dilatation.
Management
- Supportive care: rest, fluids and avoidance of alcohol and hepatotoxic drugs.
- Review the drug list: stop any medicine that may be the cause.
- Repeat bloods: to confirm the ALT is falling and the INR remains normal.
- Public health: acute infectious hepatitis is notifiable, and contacts may need vaccine.
Referral
Unexplained clinical jaundice warrants urgent referral. Admit the same day if there is encephalopathy or a prolonged prothrombin time, since these mark liver failure. A well patient with a falling ALT and normal clotting can be managed at home with repeat bloods, clear safety-netting and follow-up of the serology results.
Prognosis
Hepatitis A causes no chronic state and no chronic liver damage, although severity increases with age. Hepatitis B occasionally causes fulminant hepatic necrosis, which is often fatal.
UK guidance
There is no NICE guideline on acute hepatitis; the closest UK standard is the BSG guideline on abnormal liver blood tests.
- A hepatitic pattern is predominantly raised ALT and AST, indicating hepatocellular injury.
- A cholestatic pattern is predominantly raised ALP and GGT.
- With marked ALT elevation above 1000 U/L, consider hepatitis A and E and cytomegalovirus.
- The standard liver aetiology screen includes abdominal ultrasound, hepatitis B surface antigen and hepatitis C antibody with PCR if positive.
- The screen adds antimitochondrial, smooth muscle and antinuclear antibodies, immunoglobulins, and simultaneous ferritin and transferrin saturation.
- Unexplained clinical jaundice is an indication for urgent referral.
Clinical application
Ask about exposures and medicines, then check liver tests, clotting and viral serology.
- Take an exposure history: travel, food, sexual contacts, injecting, alcohol, paracetamol and new medicines.
- Request liver tests with INR, and hepatitis serology guided by the size of the ALT rise.
- Arrange urgent assessment for unexplained jaundice, and admit if confused or bleeding.
- Notify suspected acute infectious hepatitis to the local health protection team.
