Hepatitis C differential diagnosis

• Abdominal pain and bloating
• Menstrual irregularities
• Symptoms of hypogonadism:
  • Impotence
  • Infertility
  • Testicular atrophy
  • Loss of libido
  • Easy bruisability

• Decompensated cirrhosis may present with
  • Jaundice
  • Increase in abdominal girth due to ascites
  • Pruritus
• Signs of upper gastrointestinal bleeding:
  • Hematemesis
  • Hematochezia
  • Melena
  • Symptoms due to hepatic encephalopathy:
  • Altered mental status
  • Confusion
  • Sleep disturbances

Ultrasound findings in cirrhosis are as follows:^{[7][8][9][10][11][12][13][14]}

• Changes in liver contour: shrunken, irregular appearance
• Non homogeneous appearance of the hepatic tissue
• Increased surface nodularity
• Increase in echogenecity from focal fatty infiltration
• Atrophy of the right lobe and hypertrophy of the caudate or left lobe
• Splenomegaly
• Ascites
• Varices
• Hepatic or portal vein thrombosis

Abdominal MRI may also be helpful in the diagnosis of portal hypertension. Findings on MRI suggestive of cirrhosis with portal hypertension include:^{[15][16][17][18]}

• Cirrhotic liver, as shrinkage and atrophy in liver
• Re-canalized umbilical vein—pathognomonic
• Dilated portal vein and/or splanchnic veins
• Esophageal varices
• Collaterals in any abdominal organ
• Splenomegaly
• Ascites

Transient elastography and the Acoustic Radiation Force Impulse (ARFI) technique are well-established methods for the staging of fibrosis in various liver diseases: ^{[19][20][21][22][23][24][25][26][27][28][29]} 

• The FibroScan (transient elastography) uses elastic waves to determine liver stiffness which theoretically may be converted into a liver score.
• The FibroScan produces an ultrasound image of the liver (from 20-80mm) along with a pressure reading (in kPa).
• Transient elastography is much faster than a biopsy (usually lasts 2.5-5 minutes) and is completely painless.
• Findings on transient elastography may show reasonable correlation with the severity of cirrhosis:^[30][31]
  • Increasing scarring of the liver is associated with increasing “stiffness” of the tissue.

• Increased jugular venous pressure
• atrial fibrillation
• tachycardia
• Quiet heart sounds with a third heart sound (ventricular knock)

• EKG will show:
  • tachycardia
  • Atrial fibrillation
  • Low-voltage QRS complexes
  • T wave abnormalities
• Doppler ultrasound shows ventricular filling abnormalities

• Abdominal pain
• Diarrhea
• Ascites

• Doppler ultrasound and CT of the abdomen shows absence of the hepatic vein filling
• Abdominal CT will show a rapid clearing of the caudate lobe of the liver

• Upper abdominal pain radiating to the back
• Vomiting
• Poor bowel sounds
• Fever
• Shock
• Cullen’s sign
• Grey-Turner’s sign

• Ultrasound of the abdomen and CT will show evidence of a splenic vein thrombosis
• Normal hepatic venous pressure gradient is present

• Symptoms depend on the underlying cause:
• If pancreatitis is present, the patient may develop:
  • Upper abdominal pain radiating to the back
  • Vomiting
  • Poor bowel sounds
  • fever
  • shock
  • Cullen’s sign
  • Grey-Turner’s sign
• If the cause is ascending cholangitis, symptoms include:
  • Fever
  • rigors
  • Right upper quadrant pain
  • Dark urine
  • Pale stools
• If abdominal sepsis is the cause, symptoms include:
• fever
• abdominal pain
• Signs of peritonitis

• Doppler ultrasound and abdominal CT show a portal vein filling defect and absence of flow in the portal vein.
• MR or direct angiography show a normal hepatic venous pressure gradient.

• Patients may have a history of travel to endemic areas
• Constitutional symptoms such as
  • Malaise
  • rigors
  • anorexia
  • weight loss
  • vomiting
  • Diarrhea
  • headache
  • Muscular aches
  • weakness
  • abdominal pain
  • urticaria
  • fever
  • lymphadenopathy

• MR or direct angiography shows a normal hepatic venous pressure gradient

• Dry cough with dyspnea
• Anterior or posterior uveitis
• dry eyes
• glaucoma
• Skin findings may include:
  • Maculopapular lesions on the face, back, arms and legs
  • erythema nodosum on the legs

• Chest x ray may show:
  • hilar lymphadenopathy
  • Upper lobe fibrosis
  • Diffuse reticulonodular shadowing
  • Liver biopsy shows non-necrotizing, non-caseating granulomas

• Signs and symptoms of renal cell carcinoma:
• Hematuria
• flank pain
• Flank or abdominal mass
• Weight loss
• hypertension

• Ultrasound of the abdomen shows evidence of inferior vena cava obstruction

• Liver biopsy shows small regenerative nodules with little or no fibrosis on reticulin staining

• Liver biopsy shows no evidence of cirrhosis

• History generally reveals exposure