What is the initial workup for a female patient presenting with acute hepatitis?

Initial Workup for Acute Hepatitis in a Female Patient

The initial workup for acute hepatitis in a female patient should include comprehensive serologic testing for viral etiologies, autoimmune markers, biochemical assessment of liver function, and imaging studies to evaluate liver structure and rule out biliary obstruction.

Initial Laboratory Evaluation

Essential Blood Tests

• Liver Function Tests:

  • Aminotransferases (AST/ALT)
  • Alkaline phosphatase and gamma-glutamyl transpeptidase (GGT)
  • Total and direct bilirubin
  • Albumin and total protein
  • Prothrombin time/INR 1

• Complete Blood Count:

  • To assess for leukocytosis, thrombocytopenia, or anemia

• Basic Metabolic Panel:

  • Sodium, potassium, chloride, bicarbonate
  • Glucose
  • Creatinine, blood urea nitrogen
  • Calcium, magnesium, phosphate 1

• Coagulation Studies:

  • Prothrombin time/INR (critical for assessing synthetic function)
  • If INR ≥1.5 with any mental status changes, this indicates acute liver failure requiring immediate hospitalization 1

Viral Hepatitis Serologies

• Hepatitis A: Anti-HAV IgM
• Hepatitis B: HBsAg, anti-HBc IgM, HBeAg, anti-HBe, HBV DNA quantification
• Hepatitis C: Anti-HCV, HCV RNA if anti-HCV positive
• Hepatitis E: Anti-HEV IgM (particularly important in pregnant women) 1
• Other viral etiologies: EBV, CMV, HSV, VZV (if immunocompromised) 1

Autoimmune Markers

• Autoantibody testing for autoimmune hepatitis 1:
  • Anti-nuclear antibody (ANA)
  • Anti-smooth muscle antibody (ASMA)
  • Anti-liver kidney microsomal antibody (anti-LKM-1)
  • Immunoglobulin G levels

Additional Tests

• Toxicology screen and acetaminophen level 1
• Ceruloplasmin level (to rule out Wilson's disease) 1
• Pregnancy test in women of childbearing age 1
• Arterial lactate (prognostic in acute liver failure) 1
• Arterial ammonia level (if encephalopathy is present) 1

Imaging Studies

• Abdominal ultrasound: First-line imaging to:

  • Assess liver size and echogenicity
  • Evaluate for biliary obstruction
  • Screen for vascular abnormalities (Budd-Chiari syndrome)
  • Rule out focal lesions 1

• Additional imaging if indicated:

  • Magnetic resonance cholangiopancreatography (MRCP): If biliary obstruction is suspected
  • CT abdomen: If ultrasound is inconclusive or to better characterize lesions

Special Considerations

Pregnancy

• Hepatitis E testing is particularly important in pregnant women, as HEV infection carries a mortality rate of approximately 56% in this population 1
• Consider obstetric causes of liver dysfunction:
  • Preeclampsia/HELLP syndrome
  • Acute fatty liver of pregnancy
  • Drug-induced hepatitis (e.g., α-methyldopa) 2

Prognostic Assessment

• MELD score calculation is recommended over Kings College Criteria for prognosis in acute liver failure 1
  • A MELD score ≥30.5 predicts poor outcomes and potential need for liver transplantation

When to Consider Liver Biopsy

• Liver biopsy is generally not recommended routinely in acute hepatitis 1
• Consider biopsy when:
  • Diagnosis remains unclear after non-invasive testing
  • Autoimmune hepatitis is strongly suspected
  • Discordance between ALT and HBV DNA results in chronic hepatitis B 1

Common Pitfalls and Caveats

1. Delayed serologic conversion: Some patients with acute viral hepatitis may initially test negative for viral markers. Consider repeat testing if clinical suspicion remains high 3

2. Non-viral etiologies: Remember to consider drug-induced liver injury, autoimmune hepatitis, Wilson's disease, and ischemic hepatitis 4

3. Acute-on-chronic presentation: Some patients may have underlying chronic liver disease with acute decompensation. Look for stigmata of chronic liver disease on physical exam 1

4. Atypical presentations: Hepatitis A can present with extrahepatic manifestations including rash and polyarthralgia 3

5. Acute liver failure recognition: Promptly identify patients with INR ≥1.5 and any mental status changes, as they require immediate hospitalization and consideration for transfer to a liver transplant center 1

By following this systematic approach to the workup of acute hepatitis in female patients, clinicians can efficiently identify the etiology and assess disease severity to guide appropriate management decisions.