The results of the tests performed by the doctor are now available (Table 5.1). HCV antibodies indicate HCV infection (chronic hepatitis) and the patient will require HCV RNA, liver biopsy and possible treatment with anti-viral therapy with pegylated interferon and ribavirin, or with one of the newer protease inhibitors (boceprevir or telaprevir).

Table 5.1 Further investigations into the cause of the abnormal liver function test

Test	Result	Implication
Repeat LFTs	Similar to above
Hepatitis A	IgG positive IgM negative	Patient has been infected with HAV in the past or immunised. This virus does not cause chronic liver disease
HBsAg	Negative	See below
HCV antibodies	Positive
Autoantibody screen	Negative	Positive titres usually found in autoimmune hepatitis
Serum ferritin	110 µg/L	This excludes hereditary haemochromatosis

Armed with the HCV result you discuss IV drug use with your patient, who then admits to the very occasional use of IV drugs in the 1960s.

Although this patient did not have HBV, you need to know the significance of HBV markers (Table 5.2).

Table 5.2 Significance of viral markers in hepatitis B

From Kumar and Clark Clinical Medicine, 8th edn, 2012.

Progress.

This patient was referred to the Liver Clinic. Her HCV RNA showed 45 000 IU/ml viral load. She was treated with pegylated interferon and ribavirin and at 3 months she had a good response with a 2 log reduction in RNA. She stopped therapy at 6 months and continued to be followed up in the clinic.

Jaundice

Jaundice is detected clinically when the serum bilirubin is greater than 50 µmol/L (3 mg/dL).

Case history (1)

A 45-year-old woman has been admitted to MAU with deep jaundice. She gives a history of two episodes of severe abdominal pain which had lasted for about half an hour. She has lost her appetite and consequently lost some weight.

Abdominal examination is unhelpful; there were no signs of chronic liver disease.

The blood tests showed a raised serum bilirubin, an ALT of 50 units and a high alkaline phosphate of 410 units. You order an ultrasound examination of the liver and biliary tree as you suspect that she has got gallstone disease (Fig. 5.1).

Figure 5.1 Clinical presentation of gallstones.

Investigations

• Blood count, liver biochemistry

• Liver function (INR and albumin)

• Abdominal ultrasound

• Viral markers to exclude hepatitis causing intra-hepatic cholestasis

Ultrasound in extra-hepatic obstruction can show:

• Dilatation of the intra-hepatic biliary tree

• Dilatation of the common bile duct

• Gallstones in the gall bladder

• Gallstones in the biliary tree

• A pancreatic mass

• Metastatic liver disease.

In this patient, the ultrasound showed gallstones in the gall bladder and a dilated common bile duct. Provided this patient’s clotting is satisfactory, the next procedure should be an ERCP. This would enable a better visualisation of the system and would allow a gallstone that is causing the obstruction in the common bile duct to be removed. A sphincterotomy would need to be performed beforehand and the stone could be removed with a basket or a balloon. If the stone is very large, the stone can be crushed and the debris removed. In an elderly patient, stent insertion to maintain drainage is an option.