Chronic Hepatitis

Approach to Evaluation

A careful history and physical examination are important but can be challenging because the onset is often insidious, and many patients are asymptomatic. Signs and symptoms, when present, are variable and can include hepatitis, fatigue, abdominal pain, anorexia, weight loss, dark urine, clay-colored stools, and fever. Some patients may receive a diagnosis after months or years of puzzling symptoms, such as relapsing jaundice. Alternatively, variceal bleeding or organomegaly can be the presenting sign. A history of exposure to blood products, use of intravenous drugs, and maternal infection are important clues to viral hepatitides. The presence of thyroiditis, Sjögren syndrome, or idiopathic colitis, especially in a female patient, raises the possibility of autoimmune hepatitis (AIH). ^, A history of exposure to drugs and toxins must also be sought.

An approach to the laboratory evaluation of children and adolescents with chronic hepatitis is shown in Box 60.1 . The pattern of biochemical abnormalities is not always diagnostic of a specific cause. Serum aminotransferase levels often are elevated but can be intermittently normal in hepatitis C virus (HCV) infection. Concentrations of serum aminotransferases often may not necessarily reflect the severity of disease identified by liver biopsy, and patients can progress to cirrhosis with normal aminotransferase levels. ^, Bilirubin elevations and concentrations of other serum enzymes, such as alkaline phosphatase and γ-glutamyltranspeptidase, can also be variable.