22 yo woman with fatigue and dark urine

[quote="MCQ"]A 22-year-old woman has had fatigue for 8 months and dark urine, which she first noticed 6 weeks ago. Positive physical findings include scleral icterus, multiple spider telangiectasias over the chest and back, a liver edge palpated 4 cm below the right costal margin, and an enlarged spleen palpated 6 cm below the left costal margin. Results of complete blood count as well as measurement of serum electrolytes, urea nitrogen, and creatinine are normal. Other laboratory tests show: Alanine aminotransferase
780 U/L Aspartate aminotransferase
680 U/L Serum bilirubin
20.8 mg/dL Direct bilirubin
8.7 mg/dL Alkaline phosphatase
145 U/L Serum albumin
2.8 g/dL Serum globulin
8.7 g/dL Prothrombin time
12 sec (international normalized ratio, 1.2) The best test to confirm the diagnosis is:
A) Endoscopic retrograde cholangiopancreatography (ERCP)
(B) Hepatoiminodiacetic acid (HIDA) scan
(C) Percutaneous liver biopsy
(D) Technetium-99m liver-spleen scan
(E) Magnetic resonance imaging of the abdomen[/quote]
Answer: C Educational Objective: Recognize autoimmune chronic hepatitis. The pattern of the liver function tests suggests some type of hepatitis. The fact that the patient has been symptomatic for more than 6 months is consistent with chronic hepatitis. A diagnosis of autoimmune chronic hepatitis, one of the most treatable types of liver disease, is strongly suggested by the striking elevation of globulins. The appropriate test to diagnose chronic hepatitis and to determine its severity is percutaneous liver biopsy. Endoscopic retrograde cholangiopancreatography (ERCP) is not helpful in these patients. An hepatoiminodiacetic acid (HIDA) scan is useful in the diagnosis of acute cholecystitis, but not in hepatitis. Technetium liver-spleen scan will not give a definite diagnosis, nor will magnetic resonance imaging of the abdomen. The clinical description is typical of autoimmune chronic hepatitis. The appropriate initial treatment for autoimmune chronic hepatitis is prednisone. Controlled trials have repeatedly shown rapid efficacy in improving symptoms, abnormal blood tests, and histologic findings in the liver.