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Volume 05

A study guide to hepatology.

For the internal medicine resident who'd rather trend LFTs than guess, keeping your knowledge detoxed and your confidence from going into failure. Last revised 2026.

08 topics

Hepatology

Biliary · Cholestasis · Metabolic · Viral · Cirrhosis · Failure

01

Disorders of the Gallbladder & Bile Ducts

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Asymptomatic Gallstones — Cholecystectomy Indications

Gallstones >3 cm · gallbladder wall calcification · gallbladder polyps >1 cm

Biliary Colic

Episodic, acute severe epigastric/RUQ pain, 30 min–6 h, nausea/vomiting › elective cholecystectomy (gallstones).

Choledocholithiasis

RUQ/epigastric pain, jaundice, hyperbilirubinemia, mixed LFTs › US, MRCP/ERCP.

US › dilated CBD, stones.

Acute Cholecystitis

Epigastric/RUQ pain, fever, Murphy’s sign, normal bilirubin, normal/minimally elevated ALT/AST, leukocytosis › US, HIDA › IV antibiotics + cholecystectomy before discharge.

US › thickened gallbladder wall, pericholecystic fluid. HIDA scan › lack of gallbladder filling.

Acalculous Cholecystitis

Critical illness › gallbladder ischemia, abdominal pain, leukocytosis, jaundice, sepsis › IV antibiotics + cholecystectomy.

RF: cardiac surgery, sepsis, burns, vasculitis.

US › pericholecystic fluid, gallbladder distention, pneumatosis, no stones.

Biliary Sludge

Biliary colic, pancreatitis. US › no gallstones or bile duct dilation.

Acute Cholangitis

Charcot’s Triad: fever, RUQ pain, jaundice. Reynolds’ Pentad: + hypotension, confusion. Leukocytosis, mixed LFTs, hyperbilirubinemia.

Workup: US, CT, MRCP, EUS.

Treatment: antibiotics (cotrimoxazole + metronidazole, tazocin, ciprofloxacin + metronidazole, carbapenem) + ERCP.

Causes: choledocholithiasis, Mirizzi syndrome, gallbladder sludge, strictures, pancreatic head tumor, hilar cholangiocarcinoma, metastases, stent blockage, PSC, HIV cholangiopathy, parasites, hemobilia.

Imaging › biliary dilatation ± stones. Failed ERCP › IR-guided percutaneous transhepatic biliary drainage.

  • Fitz-Hugh-Curtis syndrome: RUQ pain, pelvic adnexal tenderness, leukocytosis, gonorrhea/chlamydia
  • Mirizzi syndrome: impacted gallstone in cystic duct › extrinsic compression › jaundice, dilated common hepatic duct
  • Cholecystoenteric fistula: biliary colic, cholecystitis, SBO, pneumobilia
02

Cholestatic Liver Diseases

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PSC

Abdominal pain, pruritus, jaundice, fatigue, elevated ALP, elevated total bilirubin › c-ANCA +ive, MRCP multifocal biliary strictures › ERCP.

RF: male, IBD (UC).

Complications: CCA, gallbladder cancer, colorectal cancer.

Surveillance: colonoscopy at diagnosis + annually (colorectal cancer). MRCP + CA19-9 annually (CCA) › biopsy. Dominant stricture / bile duct mass › ERCP.

CCA › surgical resection + adjuvant capecitabine.

Cirrhosis › US + AFP 6-monthly (HCC) + EGD (varices).

Cirrhosis + CCA or liver failure › liver transplantation.

PBC

Pruritus, fatigue, weight loss, jaundice, elevated ALP › ALP ≥1.5× ULN + AMA +ive, liver biopsy (AMA −ive or ALP <1.5× ULN) › UDCA.

RF: middle-aged female, Sjögren, celiac disease, autoimmune thyroid disease.

Complications: fat-soluble vitamin deficiencies, osteoporosis, osteomalacia.

Decompensated cirrhosis or refractory › liver transplantation.

Monitoring: annual TSH, DEXA scan 2-yearly. Cirrhosis › US + AFP 6-monthly (HCC).

03

Metabolic Liver Diseases

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Wilson’s Disease

Autosomal recessive, ATP7B mutation. Elevated LFTs, steatosis, cirrhosis, ALF, dysarthria, tremor (postural > rest), dystonia, parkinsonism, mood/behavioral changes, psychosis, KF rings, sunflower cataracts, hemolytic anemia (DAT −ive), AKI, Fanconi syndrome, cardiac, bone, infertility.

Workup: ↓ceruloplasmin, ↑24h urinary copper, genetic testing, slit lamp (KF rings), MRI brain (neurologic symptoms).

Treatment: chelators (D-penicillamine, trientine) +/− zinc.

Unclear diagnosis › liver biopsy. Monitor: LFTs, ceruloplasmin, urinary copper.

Decompensated cirrhosis / ALF › liver transplant.

MASLD

Mildly elevated aminotransferase levels, steatosis (US, CT, MRI, histology, fibroscan) › weight loss, statins, diet modification, exercise, semaglutide, tirzepatide.

RF: T2DM, DLP, HTN, obesity, metabolic syndrome, OSA, PCOS, hypogonadism, hypothyroidism.

Screening indications: T2DM, obesity + metabolic complications, 1st degree relative with MASH cirrhosis, alcohol use › FIB-4 score.

FIB-4 >1.3 › fibroscan. FIB-4 <1.3 › FIB-4 1–3 yearly.

BMI ≥35 › bariatric surgery. DLP/DM treatment. F≥2 › EtOH abstinence. Moderate/severe fibrosis › resmetirom.

Gilbert Syndrome

UGT1A1 gene variation, asymptomatic mild jaundice › unconjugated hyperbilirubinemia >80%, total bilirubin ≤5, normal LFTs, normal hemolysis studies.

Triggers: fasting, physical exertion, stress.

04

Alcohol-Induced Liver Disease

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General Care

Nutrition: 35 kcal/kg/d, 1.2–1.5 g/kg/d protein, +/− thiamine supplementation, +/− zinc supplementation.

Workup: fibroscan (cirrhosis). EtOH cessation.

  • Alcoholic Hepatitis (AH): jaundice ≤60 days heavy alcohol use, leukocytosis, tender hepatomegaly, +/− fever, portal HTN, AST/ALT <300–500, AST:ALT >2, total bilirubin >51
  • Severe AH: MELD >20
  • Severe AH or encephalopathy › prednisolone 40 mg OD ×4 weeks + IV NAC
    • Prognosis: Lille score days 1 and 7, no improvement › DC steroids
    • Steroid CI: GI bleeding, infection, multiorgan failure, concomitant liver disease, severe kidney injury
05

Hepatitis

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HAV

Fecal-oral, self-limited, acute onset, fatigue, anorexia, malaise, nausea, vomiting, jaundice, ALT/AST >1000 › anti-HAV IgM › supportive treatment.

Vaccination indications (single dose): travel to endemic countries, CLD, MSM, IVDU, HIV, homelessness, primate handlers, pregnancy + RF, close contacts adoptees endemic areas.

Post-exposure: household contacts, co-workers/clients of infected food handlers, childcare contacts + unvaccinated › HAV vaccine ≤2 weeks +/− HAIG (age >40y, CLD, immunocompromised).

Fulminant hepatitis › transplant.

Acute HBV

Blood/body fluids (IVDU, sexual contact), vertical transmission, acute onset, fatigue, anorexia, malaise, nausea, vomiting, jaundice, elevated ALT/AST › HBsAg, anti-HBc IgM, HBeAg, HBV DNA › supportive.

Test for co-infections: HCV, HDV, HIV, syphilis, gonorrhea, chlamydia.

HBsAg +ive ≥6 months › chronic HBV.

Fulminant hepatitis › antivirals.

Post-exposure: household/sexual contacts or needlestick injury + unvaccinated (anti-HBs <10) › vaccination ≤48h +/− HBIG (blood/body fluids, sexual contact, needle sharing).

Resolved: anti-HBs, anti-HBc IgG. Vaccinated: anti-HBs.

Resolved + immunosuppression › antivirals.

HBV — HCC Risk Factors

Age >40 · male · immunocompromised · HIV/HCV/HDV co-infection · alcohol use · metabolic syndrome · FH HCC · sub-Saharan African, Asian · aflatoxin exposure · smoking · persistently elevated ALT + HBV DNA >10,000 · prolonged time to HBeAg seroconversion · HBeAg −ive · HBV Genotype C · persistent HBsAg

Chronic HBV

Markers: HBsAg, anti-HBc IgG, HBV DNA, +/− HBeAg, +/− anti-HBe › fibroscan.

Immune tolerant: HBsAg, anti-HBc, HBeAg, high HBV DNA, normal ALT/AST.

Immune active: HBsAg, anti-HBc IgG, high HBV DNA, +/− HBeAg, +/− anti-HBe, elevated ALT/AST.

Inactive: HBsAg, anti-HBc IgG, low HBV DNA, anti-HBe, normal ALT/AST › ALT + HBV DNA every 6–12 months.

Extra-hepatic: membranous nephropathy, MPGN, aplastic anemia, cryoglobulinemia, PAN.

Screening indications: age ≥18y, birth in endemic areas, household contacts, HBV+ sexual partner, IVDU, prisoners, dialysis, elevated LFTs, pregnancy, immunosuppressive therapy.

Monitoring: ALT + HBV DNA every 6–12 months, HBsAg every 1–2y. HCC surveillance if cirrhosis/RF: abdominal US + AFP 6-monthly.

Chronic HBV — Treatment

Cirrhosis RF: age >40y, male, immunocompromised, HIV/HCV/HDV co-infection, alcohol use, metabolic syndrome, high HBV DNA (≥2000), elevated ALT, prolonged time to HBeAg seroconversion, HBeAg −ive, HBV Genotype C.

Treatment indications: ALF, cirrhosis, HCC, immunosuppressive therapy, extrahepatic manifestations, HBV DNA >2000 + ↑ALT >ULN ×3–6 months, HBV DNA >2000 + age ≥40y, HBV DNA >2000 + ≥F2, HBV DNA >2000 + LSM ≥7, HBV DNA >2000 + FH HBV cirrhosis/HCC, pregnancy + HBV DNA >200,000 › tenofovir or entecavir.

Pregnancy › tenofovir, infant HBIG + HBV vaccine ≤12h, complete primary series ≤6 months.

HIV › emtricitabine-tenofovir.

Chronic HCV

Markers: anti-HCV, HCV RNA, HCV genotype › sofosbuvir/velpatasvir (Epclusa) or glecaprevir/pibrentasvir (Maviret) › HCV RNA 12 weeks post-treatment.

Test for co-infections: HBV, HIV, syphilis, gonorrhea, chlamydia. Baseline abdominal US + fibroscan.

Screening indications: age ≥18y, pregnancy, IVDU, blood transfusion <1992, born/lived endemic area, HCV mother, incarceration, HIV, STI, sexual contact, elevated ALT, HD, MPGN, porphyria cutanea tarda, NHL, cryoglobulinemia.

Cirrhosis RF: older age, male, HIV/HBV, obesity, DM, fatty liver, alcohol abuse.

Extrahepatic: autoimmune thyroid disease, Sjögren’s, MPGN, membranous nephropathy, porphyria cutanea tarda, leukocytoclastic vasculitis, NHL, autoimmune hemolytic anemia, ITP, cryoglobulinemia, insulin resistance.

MELD ≥15 or HCC or decompensated cirrhosis › liver transplantation.

Cirrhosis › US + AFP 6-monthly (HCC). Antivirals › HBV re-activation.

Autoimmune Hepatitis

Female, aged 20–40y, asymptomatic, acute hepatitis, ALF, chronic hepatitis, cirrhosis, elevated IgG › liver biopsy › glucocorticoids +/− AZA.

Type 1: ANA, ASMA; autoimmune thyroid disease, UC, celiac, T1DM.

Type 2: children, young adults, anti-LKM1, p-ANCA, APECED.

Screening: celiac disease, thyroid disease.

06

Pregnancy-Related Liver Disease

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Hyperemesis Gravidarum

1st trimester, severe vomiting, 5% weight loss, dehydration, elevated ALT/AST, normal bilirubin, ketosis, electrolyte imbalance › hydration, pyridoxine, antiemetics.

IHCP

2nd/3rd trimester, pruritus (palms/soles, worse at night), elevated bile acids >10, elevated ALP, normal/elevated ALT/AST, normal/elevated bilirubin › UDCA.

↑Risk GDM, HTN, preeclampsia.

Preeclampsia

3rd trimester, HTN, edema, proteinuria, mildly increased ALT/AST, normal bilirubin › delivery.

HELLP

3rd trimester, preeclampsia, abdominal pain, nausea, MAHA, elevated ALT/AST, thrombocytopenia <100 › delivery.

AFLP

3rd trimester, vomiting, abdominal pain, encephalopathy, jaundice, ascites, polydipsia, polyuria, hemolysis, elevated ALT/AST, thrombocytopenia, hypoglycemia, coagulopathy, elevated bilirubin › delivery.

ALF › liver transplant. Newborn screening: LCHAD.

  • HBV DNA >200,000 › tenofovir, lamivudine
    • Newborn HBIG + HBV vaccination ≤12h
07

Liver Lesions

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HCC

RF: cirrhosis, HBV.

Screening indications: Child-Pugh A/B, Child-Pugh C + transplant candidate, HBsAg + Asian (male age ≥40, female age ≥50y), HBsAg + FH HCC 1st degree (age ≥40y), HBsAg + HIV (age ≥40y), HBsAg + sub-Saharan African (age ≥20y), HBsAg + HDV › US + AFP 6-monthly.

Diagnosis: contrast-enhanced CT/MRI liver › arterial enhancement › liver transplant. Child-Pugh A + single lesion ≤5 cm › resection.

Hepatic Adenoma

Heterogeneous › DC OCP.

Resection indications: male, female + ≥5 cm.

Focal Nodular Hyperplasia

Central stellate scar.

Metastatic Tumors

US › hypoechoic lesions; contrast-enhanced CT › hypovascular.

Isolated › resection.

Amebic Liver Abscess

RUQ pain, fever › US/CT (heterogeneous, irregular margins), E. histolytica serology › metronidazole/tinidazole + paromomycin.

08

Advanced CLD & Liver Failure

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Cirrhosis — General Management

Alcohol abstinence, limit paracetamol ≤2 g/day, adequate nutrition, avoid sedatives/NSAIDs/ACEi/ARBs.

Etiologies: viral, ALD, MASLD, AIH, PBC, PSC, Wilson, HH, A1ATD, chronic biliary disease, right-sided HF, Budd-Chiari syndrome.

Prognosis: Child-Pugh score (ascites, bilirubin, INR, albumin, encephalopathy). MELD ≥15 › liver transplant referral.

Complications: EV, ascites, SBP, HE, HRS, HPS, porto-pulmonary HTN, HCC.

CSPH

Fibroscan › LSM ≥25 kPa, LSM ≥20 + Plt <150, LSM 15–19.9 + Plt <110, EV › NSBB (carvedilol, propranolol, nadolol).

Esophageal Varices

EGD at diagnosis and decompensation › NSBB (high-risk) › EVL.

Acute variceal hemorrhage › EVL ≤12h + ceftriaxone + IV octreotide ×2–5d › NSBB.

Low-risk › EGD 1–3 yearly.

HCC Surveillance

US + AFP at diagnosis + 6-monthly.

Ascites / Hepatic Hydrothorax

US › treat underlying liver disease, salt restriction <2 g/d › diuretics (spironolactone +/− furosemide 10:4).

Na <125 › fluid ≤1 L/d.

Refractory › large volume paracentesis (albumin 6–8 g/L >5L), TIPS (CI: encephalopathy, HCC, pulmonary HTN, right-sided HF), liver transplant.

New-onset ascites, hospital admission, or signs of SBP › paracentesis. SAAG ≥11: portal HTN. SAAG <11: nephrotic syndrome / malignancy / TB.

SBP

Diagnosis: ascitic fluid PMN ≥250 or ascitic fluid culture +ive › ceftriaxone/cefotaxime/fluoroquinolone ×5d + albumin.

HRS prophylaxis: day 1 albumin 1.5 g/kg › day 3 albumin 1 g/kg.

Prophylaxis indications: secondary, ascitic fluid total protein <1.5 + bilirubin ≥51 / BUN ≥25 / creatinine ≥106 / sodium ≤130 › norfloxacin or cotrimoxazole or ciprofloxacin.

GI bleed › SBP prophylaxis ×5d.

HRS

Cirrhosis + ascites + impaired renal function, no other cause › DC diuretics + albumin + vasoactive agent (terlipressin, norepinephrine, midodrine, octreotide) › dialysis › liver transplant.

HRS-AKI (HRS1): ↑Cr ≥26 / ↑≥50% ≤48h, no improvement with withdrawal of diuretics + 2 days IV albumin, low urine Na, low FeNa, oliguria.

HRS-CKD (HRS2): gradual decline in kidney function, diuretic-refractory ascites.

HPS

Dyspnea, platypnea, hypoxemia, increased A-a gradient.

TTE + agitated saline › intrapulmonary shunting › liver transplant.

Hepatic Encephalopathy

Day-night sleep reversal, drowsiness, agitation, confusion, coma › lactulose +/− rifaximin.

Triggers: SBP, infection, GI bleeding, alcohol, drugs, HCC, stroke, constipation, dehydration, portal/hepatic VTE, electrolyte abnormalities, TIPS, sedatives.

Prophylaxis: lactulose.

Porto-Pulmonary HTN

TTE › RVSP >50.

Hepatic Osteodystrophy

Osteoporosis, osteopenia, osteomalacia › DEXA › calcium + vitamin D + IV bisphosphonate.

Vaccinations in CLD

HAV, HBV, COVID-19, TdAP, pneumococcal, influenza, HZV (age >50y), RSV (age >60y).

  • ALF: elevated ALT/AST, encephalopathy, coagulopathy
    • Causes: paracetamol OD, drug reactions (co-amoxiclav, phenytoin, valproate), acute HBV, HAV, hepatic ischemia, herpes, mushroom poisoning, Wilson disease
  • Liver transplant indications: MELD ≥15, ALF, decompensated cirrhosis, HCC