A 52-year-old woman is hospitalized because she has had jaundice, anorexia, and occasional nausea and vomiting for about 2 weeks. She has also had moderate pain in the epigastrium and right upper quadrant, but it has not been severe enough to require analgesics. She denies hematemesis and hematochezia. HISTORY
Until now, the patient has been healthy; she takes no medications. However, she drinks about half a bottle of whiskey per day and likely consumes more on weekends. She does not smoke and has never abused drugs. During the month before admission, she has been depressed; she has engaged in binge drinking, has eaten very little, and has missed work for the past 2 weeks. PHYSICAL EXAMINATION
Temperature is 38.2oC (100.8oF); heart rate, 108 beats per minute; and blood pressure, 130/75 mm Hg. Oxygen saturation on room air is normal. No lymphadenopathy or oral lesions are noted, but mucous membranes are dry. Two spider angiomata are present on the left shoulder. Heart and lungs are normal. Abdomen is soft, with good bowel sounds and no appreciable ascites. There is tender hepatomegaly; the liver edge is palpable 4 finger-widths below the ribs and crossing into the midline. Below the knees, 2+ edema is present. Mentation is slow but oriented. Stool is heme-negative on 2 examinations. The morning after admission, asterixis is noted. LABORATORY AND IMAGING RESULTS
Hemoglobin level is 10.5 g/dL. White blood cell count is 19,000/μL with 90% neutrophils and a slight left shift. Mean corpuscular volume is 105 fL. Serum sodium level is 112 mEq/L; chloride level, 91 mEq/L; and potassium level, 3.4 mEq/L. Creatinine level is 1.7 mg/dL and blood urea nitrogen level, 29 mg/dL. Bilirubin level is 22 mg/dL; alkaline phosphatase level, 673 U/L; aspartate transaminase (AST) level, 211 U/L; and alanine transaminase (ALT) level, 55 U/L. Prothrombin time (PT) is 27 seconds, and INR is 2.3 (with a control PT of 12 seconds). Abdominal ultrasonography reveals significant hepatomegaly and moderate splenomegaly, no gallstones or dilated bile ducts, a patent portal vein, and no ascites. Which of the following is the most appropriate next step? A.Urgent surgical consultation for cholecystectomy and bile duct exploration. B.Detailed blood testing for hepatitis C genotype and viral load titer. C.Prompt, aggressive diuresis with loop diuretics. D.Administration of corticosteroids and pentoxifylline (after infection is excluded by appropriate cultures and studies).
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