Study guide
3.6 Viral Hepatitis, Steatotic & Alcohol-Associated Liver Disease
ABIM Internal Medicine Exam
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1 Chapter 0: The ABIM Exam, Blueprint & Study Strategy
0.1 Exam Format, Question Types & the 2026 Blueprint 0.2 Eligibility, Registration, Fees & Exam-Day Logistics 0.3 Scoring, the Passing Standard & Score Reports 0.4 Building a Blueprint-Weighted Study Plan
2 Chapter 1: Cardiovascular Disease (14% of Exam)
1.1 Ischemic Heart Disease & Acute Coronary Syndromes 1.2 Antithrombotic Therapy, Secondary Prevention & Mechanical Complications of MI 1.3 Atrial Fibrillation, Atrial Flutter & Stroke Prevention 1.4 Supraventricular Tachycardias, Ventricular Arrhythmias & Bradycardias 1.5 Heart Failure: Classification, Staging & Guideline-Directed Medical Therapy 1.6 Device Therapy, HFpEF & the Cardiomyopathies 1.7 Valvular Heart Disease & Endocarditis Prophylaxis 1.8 Pericardial Disease & Acute Aortic Syndromes 1.9 Hypertension: Classification, Diagnosis & Secondary Causes 1.10 Hypertensive Crises & Dyslipidemia 1.11 Adult Congenital Heart Disease & Coarctation of the Aorta 1.12 Syncope: Reflex, Orthostatic & Cardiac Causes 1.13 Cardiac Physical Examination, Murmurs & Antithrombotic Selection
3 Chapter 2: Endocrinology, Diabetes & Metabolism (9% of Exam)
2.1 Diabetes Mellitus: Diagnosis, Glycemic Targets & Pharmacotherapy 2.2 Insulin Therapy, Hyperglycemic Emergencies & Chronic Complications 2.3 Thyroid Function Testing & Hypothyroidism 2.4 Thyrotoxicosis, Thyroid Storm & Thyroid Nodules 2.5 Adrenal & Pituitary Disorders 2.6 Hypercalcemia, Hypocalcemia & Disorders of Mineral Metabolism 2.7 Osteoporosis & Paget Disease of Bone 2.8 Ovarian, Testicular & Reproductive Endocrine Disorders 2.9 Hypoglycemia, Endocrine Tumors, Polyglandular Syndromes & Severe Hypertriglyceridemia
4 Chapter 3: Gastroenterology & Hepatology (9% of Exam)
3.1 Esophageal Disease 3.2 Stomach & Duodenal Disease and Gastrointestinal Hemorrhage 3.3 Inflammatory Bowel Disease 3.4 Celiac Disease & Irritable Bowel Syndrome 3.5 Diverticular Disease & Colorectal Cancer Screening 3.6 Viral Hepatitis, Steatotic & Alcohol-Associated Liver Disease 3.7 Cirrhosis & the Complications of Portal Hypertension 3.8 Acute Pancreatitis 3.9 Chronic Pancreatitis & Biliary Tract Disease 3.10 Inherited, Autoimmune & Drug-Induced Liver Disease 3.11 Small Intestinal Disease, Ischemia & Gastrointestinal Complications of HIV
5 Chapter 4: Infectious Disease (9% of Exam)
4.1 Lower Respiratory Tract Infections & Sepsis Syndromes 4.2 Viral Respiratory Pathogens & Tuberculosis 4.3 Central Nervous System Infections 4.4 Skin, Soft Tissue, Bone & Joint Infections 4.5 Infective Endocarditis & Cardiovascular Infection 4.6 Clostridioides difficile & Catheter-Related Bloodstream Infection 4.7 HIV Diagnosis, Antiretroviral Therapy & Prevention 4.8 Opportunistic Infections & Sexually Transmitted Infections 4.9 Fever of Unknown Origin, Neutropenic Fever & Toxic Shock 4.10 Travel-Related Illness, Vector-Borne Disease & Outbreaks 4.11 Infection Prevention, Nosocomial Infection & Postexposure Prophylaxis 4.12 Rheumatic Fever, Poststreptococcal Disease, Enteric & Hepatic Infections
6 Chapter 5: Pulmonary Disease (9% of Exam)
5.1 COPD: Diagnosis, GOLD Classification & Initial Pharmacotherapy 5.2 Interventions That Reduce COPD Mortality & Exacerbation Management 5.3 Asthma: Diagnosis, Stepwise Therapy & Status Asthmaticus 5.4 Interstitial Lung Disease & Idiopathic Pulmonary Fibrosis 5.5 Sarcoidosis, Hypersensitivity Pneumonitis & Occupational Lung Disease 5.6 Pulmonary Embolism: Diagnosis, Risk Stratification & Anticoagulation 5.7 Pulmonary Hypertension & Sleep-Disordered Breathing 5.8 Acute Respiratory Distress Syndrome & Mechanical Ventilation 5.9 Pleural Disease, Empyema & Pneumothorax 5.10 Bronchiectasis, Cystic Fibrosis & Restrictive Lung Disease 5.11 Evaluation of Cough, Dyspnea, Hemoptysis & the Solitary Pulmonary Nodule
7 Chapter 6: Rheumatology & Orthopedics (9% of Exam)
6.1 Rheumatoid Arthritis: Diagnosis & Systemic Manifestations 6.2 Antirheumatic Pharmacotherapy & the Spondyloarthropathies 6.3 Gout: Pathophysiology & Acute Management 6.4 Urate-Lowering Therapy & Calcium Pyrophosphate Deposition Disease 6.5 Osteoarthritis 6.6 Systemic Lupus Erythematosus 6.7 Systemic Sclerosis, Sjogren Syndrome & Inflammatory Myopathies 6.8 The Vasculitides 6.9 Regional Musculoskeletal Syndromes, Back Pain & Sports Injuries 6.10 Other Primary Rheumatic Disorders & Mixed Connective Tissue Disease 6.11 Osteonecrosis & Metabolic Bone Disease
8 Chapter 7: Hematology (6% of Exam)
7.1 Approach to Anemia & the Microcytic Anemias 7.2 Macrocytic, Normocytic & Hemolytic Anemias 7.3 Hemoglobinopathies, Thalassemias & Paroxysmal Nocturnal Hemoglobinuria 7.4 Platelet Disorders, Thrombocytopenia & the Bleeding Patient 7.5 Coagulation Factor Disorders, Thrombophilia & Anticoagulant Reversal 7.6 Acute Leukemias, Chronic Leukemias & Myeloproliferative Neoplasms 7.7 Lymphomas & Plasma Cell Disorders 7.8 Myelodysplastic Syndrome, Myeloproliferative Neoplasms & Porphyria 7.9 Transfusion Medicine & Late Complications of Transplantation
9 Chapter 8: Medical Oncology (6% of Exam)
8.1 Breast, Lung, Colorectal & Prostate Cancer 8.2 Oncologic Emergencies 8.3 Genitourinary & Gynecologic Malignancies 8.4 Head and Neck, Bone & Soft Tissue Cancer and Cancer of Unknown Primary 8.5 Complications of Cancer & Its Treatment 8.6 Cancer Prevention, Survivorship & Psychosocial Care
10 Chapter 9: Nephrology & Urology (6% of Exam)
9.1 Acute Kidney Injury: Staging, Etiology & Urine Microscopy 9.2 Glomerular Disorders & Nephrotic Syndrome 9.3 Nephritic Syndromes, RPGN & Indications for Renal Replacement Therapy 9.4 Chronic Kidney Disease: Staging & Progression Retardation 9.5 Complications of Chronic Kidney Disease: Anemia, CKD-MBD & Acidosis 9.6 Hyponatremia, Hypernatremia & Water Balance 9.7 Potassium Disorders & Systematic Acid-Base Analysis 9.8 Renal Tubular Acidosis & Nephrolithiasis 9.9 Prostate Disorders, Urinary Incontinence & Other Urologic Conditions 9.10 Cystic Kidney Disease, Obstructive Uropathy, Tubulointerstitial Disease & Hematuria
11 Chapter 10: Neurology (4% of Exam)
10.1 Acute Ischemic Stroke: Syndromes & Reperfusion 10.2 Transient Ischemic Attack, Secondary Prevention & Hemorrhagic Stroke 10.3 Headache & Facial Pain 10.4 Seizures, Epilepsy & Movement Disorders 10.5 Multiple Sclerosis & Neuromuscular Junction Disorders 10.6 Motor Neuron Disease & Acute Peripheral Neuropathy 10.7 Cranial Neuropathies & Neuro-Ophthalmology 10.8 Peripheral Neuropathies, CNS Tumors & Other Neurologic Disorders
12 Chapter 11: Psychiatry & Behavioral Health (4% of Exam)
11.1 Major Depressive Disorder & Medical Mimics 11.2 Antidepressant Pharmacotherapy & Treatment-Resistant Depression 11.3 Bipolar Disorder, Mood Stabilizers & Lithium Toxicity 11.4 Anxiety, Stress-Related & Obsessive-Compulsive Disorders 11.5 Alcohol Use Disorder & Withdrawal 11.6 Pharmacotherapy for Alcohol & Opioid Use Disorder 11.7 Toxidromes, Psychiatric Emergencies & Suicide Risk Assessment 11.8 Psychotic, Somatic Symptom, Factitious & Personality Disorders 11.9 Eating Disorders, Sleep Disorders & Sexual Health
13 Chapter 12: Dermatology (3% of Exam)
12.1 Dermatitis, Papulosquamous & Inflammatory Dermatoses 12.2 Acne, Rosacea & Cutaneous Infections 12.3 Herpes Zoster & Autoimmune Blistering Diseases 12.4 Nodules, Tumors & Cutaneous Oncology 12.5 Dermatologic Emergencies & Severe Cutaneous Adverse Reactions 12.6 Pigment Disorders, Alopecia, Nail Disease & Photosensitivity 12.7 Vascular Dermatoses, Environmental Injury & Cutaneous Signs of Systemic Disease
14 Chapter 13: Obstetrics & Gynecology / Women's Health (3% of Exam)
13.1 Contraception, Preconception Care & Teratogenicity 13.2 Hypertensive Disorders of Pregnancy & Gestational Diabetes 13.3 Thyroid Disease & Venous Thromboembolism in Pregnancy 13.4 Menopause & Menopausal Hormone Therapy 13.5 Abnormal Uterine Bleeding, Endometrial Disease & Gynecologic Cancer Screening 13.6 Breast Disorders & Diseases of the Vulva and Vagina 13.7 Menstrual Disorders, Fibroids, Endometriosis & Early Pregnancy Complications
15 Chapter 14: Geriatric Syndromes (3% of Exam)
14.1 Comprehensive Geriatric Assessment & Frailty 14.2 Falls, Gait Assessment & Polypharmacy 14.3 Urinary Incontinence & Pressure Injuries in Older Adults 14.4 Mild Cognitive Impairment, Dementia & Its Subtypes 14.5 Delirium & the Pharmacotherapy of Cognitive Disorders 14.6 Palliative Care, Hospice & Advance Care Planning 14.7 Chronic Wounds, Nutrition, Swallowing, Constipation & Hip Fracture 14.8 Sensory Impairment, Dizziness, Elder Mistreatment & Care Settings
16 Chapter 15: Allergy & Immunology (2% of Exam)
15.1 Anaphylaxis: Recognition & Emergency Management 15.2 Urticaria & Angioedema 15.3 Drug Allergy, Desensitization & Adult Immunodeficiency 15.4 Food Allergy, Insect Venom Hypersensitivity, Serum Sickness & Contrast Reactions 15.5 Rhinitis, Conjunctivitis, Eosinophilic & Mast Cell Disorders
17 Chapter 16: Preventive Medicine, Immunization & Clinical Epidemiology
16.1 The USPSTF Framework & Evidence-Based Cancer Screening 16.2 Cardiovascular & Metabolic Screening and Primary Prevention 16.3 Adult Immunization & Vaccines in Special Populations 16.4 Clinical Epidemiology, Biostatistics & Study Design
18 Chapter 17: Miscellaneous - Ethics, Patient Safety & Quality Improvement (2% of Exam)
17.1 Principles of Bioethics & Decisional Capacity 17.2 Informed Consent, Treatment Refusal & Special Scenarios 17.3 Surrogate Decision-Making, Advance Directives & Confidentiality 17.4 Patient Safety Science, Medical Error & Diagnostic Reasoning 17.5 Quality Improvement Methods, Health Disparities & Health Equity
19 Chapter 18: Perioperative Medicine & Medical Consultation
18.1 Preoperative Cardiovascular Risk Assessment 18.2 Preoperative Pulmonary Risk & Perioperative Medication Management 18.3 Perioperative Anticoagulation, Bridging & Postoperative Complications
20 Chapter 19: Ophthalmology (1% of Exam)
19.1 The Acute Red Eye & Ophthalmic Emergencies 19.2 Painless Vision Loss & Chronic Ophthalmic Disease 19.3 Uveitis, Scleritis & Orbital Disease
21 Chapter 20: Otolaryngology & Dental Medicine (1% of Exam)
20.1 Dizziness, Vertigo & Epistaxis 20.2 Ear Disorders, Hearing Loss & Upper Respiratory Infections 20.3 Oral Cavity, Salivary Gland, Laryngeal & Taste and Smell Disorders
3.6 Viral Hepatitis, Steatotic & Alcohol-Associated Liver Disease
Key Takeaways Explain This Topic AI
Viral hepatitis, fatty liver and steatohepatitis, alcoholic hepatitis and drug-induced liver disease are all enumerated within the liver disease blueprint subsection.
Isolated hepatitis B surface antibody indicates immunity, whereas surface antigen with core IgM indicates acute infection and surface antigen persisting beyond six months indicates chronic infection.
Hepatitis B reactivation risk requires screening before immunosuppressive or anti-CD20 therapy, with antiviral prophylaxis in those at risk.
Nearly all chronic hepatitis C is curable with direct-acting antiviral therapy, and treatment is recommended regardless of fibrosis stage.
Corticosteroids are considered in severe alcohol-associated hepatitis, and a Lille score indicating non-response after one week signals that steroids should be stopped.
Last updated: August 2026
Hepatology represents one of the highest-yield domains on the ABIM examination. Board candidates must be proficient in viral hepatitis serology, non-invasive fibrosis scoring for steatohepatitis, alcoholic hepatitis prognostic models, and the comprehensive algorithmic management of decompensated cirrhosis.
- 1. Viral Hepatitis
- Hepatitis B Virus (HBV) Serologic Profiling HBsAg (+) ➔ Active Infection (Acute or Chronic)
- Anti-HBs (+) ➔ Immunity (Vaccination or Resolved Natural Infection)
- Anti-HBc IgM (+) ➔ Acute Infection (Sole marker positive during 'Window Period')
- Anti-HBc IgG / Total (+) ➔ Prior Natural Infection (Never positive after vaccination alone)
- HBeAg (+) / High HBV DNA ➔ Active Viral Replication & High Infectivity
- Clinical State HBsAg Anti-HBs Anti-HBc IgM Anti-HBc IgG HBeAg / Anti-HBe HBV DNA
- Acute HBV Infection (+) (-) (+) (-) HBeAg (+) High ( > 10 7 IU/mL >10^7\text{ IU/mL} > 1 0 7 IU/mL )
- Window Period (Acute) (-) (-) (+) (-) Variable Low / Detectable
- Resolved Natural HBV (-) (+) (-) (+) Anti-HBe (+) Undetectable
- Vaccine-Induced Immunity (-) (+) (-) (-) (-) / (-) Undetectable
Chronic HBV (Immune Active) (+) (-) (-) (+) HBeAg (+) or (-) > 2 , 000 − 20 , 000 IU/mL >2,000-20,000\text{ IU/mL} > 2 , 000 − 20 , 000 IU/mL
Chronic HBV (Inactive Carrier) (+) (-) (-) (+) Anti-HBe (+) < 2 , 000 IU/mL <2,000\text{ IU/mL} < 2 , 000 IU/mL (ALT normal)
- Occult HBV / Isolated Anti-HBc (-) (-) (-) (+) Variable Usually undetectable
- Indications for HBV Antiviral Therapy (AASLD Guidelines)
Immune-Active Chronic HBV: Elevated ALT ( > 2 × ULN >2\times\text{ ULN} > 2 × ULN ) AND elevated viral load ( HBV DNA > 20 , 000 IU/mL \text{HBV DNA} > 20,000\text{ IU/mL} HBV DNA > 20 , 000 IU/mL if HBeAg positive; HBV DNA > 2 , 000 IU/mL \text{HBV DNA} > 2,000\text{ IU/mL} HBV DNA > 2 , 000 IU/mL if HBeAg negative).
Cirrhosis (Compensated or Decompensated): Any patient with cirrhosis and detectable HBV DNA, regardless of ALT level.
Immunosuppression Prophylaxis: Any patient who is HBsAg positive OR Anti-HBc positive undergoing B-cell depleting chemotherapy (e.g., Rituximab), anti-TNF therapy, or high-dose corticosteroids must receive prophylactic oral antiviral therapy to prevent fatal HBV reactivation.
First-Line Antiviral Regimens (High Barrier to Resistance)
Entecavir (ETV): 0.5 mg PO daily (1.0 mg PO daily in decompensated cirrhosis or lamivudine resistance).
Tenofovir Disoproxil Fumarate (TDF): 300 mg PO daily (monitor for renal tubular dysfunction and bone mineral density loss).
Tenofovir Alafenamide (TAF): 25 mg PO daily (preferred in patients with renal insufficiency [ eGFR ≥ 15 mL/min \text{eGFR} \ge 15\text{ mL/min} eGFR ≥ 15 mL/min ], osteoporosis, or age > 60 >60 > 60 ).
Hepatitis C Virus (HCV)
Universal Screening: Universal one-time screening for all adults aged ≥ 18 \ge 18 ≥ 18 years (and with every pregnancy) using Anti-HCV Antibody with reflex to quantitative HCV RNA PCR .
Diagnostic Rule: Anti-HCV Ab (+) followed by HCV RNA (+) indicates active chronic viremia . If Anti-HCV Ab (+) but HCV RNA (-), this represents spontaneously resolved past infection (~20–25% of acute cases) or successfully treated infection.
Direct-Acting Antivirals (DAAs): Oral, interferon-free regimens administered for 8 to 12 weeks achieve > 95 − 98 % >95-98\% > 95 − 98% Sustained Virologic Response (SVR12) , defined as undetectable HCV RNA 12 weeks after treatment completion (equating to virologic cure).
Glecaprevir / Pibrentasvir (Mavyret): 3 tablets once daily with food for 8 weeks in treatment-naive non-cirrhotic or compensated cirrhotic patients.
Sofosbuvir / Velpatasvir (Epclusa): 1 tablet once daily for 12 weeks .
Critical Black Box Pre-Treatment Check: Must screen for Hepatitis B (HBsAg, Anti-HBc) prior to initiating DAAs because rapid HCV eradication can trigger fulminant, fatal HBV reactivation .
- 2. Steatotic & Alcohol-Associated Liver Diseases
- Metabolic Dysfunction-Associated Steatotic Liver Disease (MASLD / MASH)
Terminology: MASLD (formerly NAFLD) requires hepatic steatosis on imaging/biopsy plus at least 1 cardiometabolic criterion (BMI ≥ 25 \ge 25 ≥ 25 , Type 2 DM, HTN, hypertriglyceridemia, or low HDL). MASH (formerly NASH) denotes steatohepatitis with hepatocyte ballooning, lobular inflammation, and progressive fibrosis.
Non-Invasive Fibrosis Risk Stratification (FIB-4 Index): FIB-4 = Age ( years ) × AST ( U/L ) Platelet Count ( 10 9 / L ) × ALT ( U/L ) \text{FIB-4} = \frac{\text{Age } (\text{years}) \times \text{AST } (\text{U/L})}{\text{Platelet Count } (10^9/\text{L}) \times \sqrt{\text{ALT } (\text{U/L})}} FIB-4 = Platelet Count ( 1 0 9 / L ) × ALT ( U/L ) Age ( years ) × AST ( U/L )
FIB-4 < 1.3 < 1.3 < 1.3 ( < 2.0 <2.0 < 2.0 if age > 65 >65 > 65 ): Low risk for advanced fibrosis. Manage in primary care; repeat every 2–3 years.
FIB-4 1.3 − 2.67 1.3 - 2.67 1.3 − 2.67 : Indeterminate risk. Reflex to Transient Elastography (FibroScan) : Liver Stiffness Measurement (LSM) < 8 kPa <8\text{ kPa} < 8 kPa (low risk), 8 − 12 kPa 8-12\text{ kPa} 8 − 12 kPa (intermediate), > 12 kPa >12\text{ kPa} > 12 kPa (advanced fibrosis/cirrhosis).
FIB-4 > 2.67 > 2.67 > 2.67 : High risk for advanced fibrosis (F3–F4). Prompt hepatology referral.
Management: Weight loss of 7 − 10 % 7-10\% 7 − 10% total body weight (reverses steatohepatitis and fibrosis); GLP-1 receptor agonists (Semaglutide, Tirzepatide); Pioglitazone; and Resmetirom (thyroid hormone receptor-beta agonist approved for non-cirrhotic MASH with moderate-to-advanced fibrosis F2–F3).
Alcohol-Associated Liver Disease & Alcoholic Hepatitis
Hallmark Laboratory Pattern: AST elevated higher than ALT with an AST : ALT Ratio > 2 : 1 \text{AST}:\text{ALT Ratio} > 2:1 AST : ALT Ratio > 2 : 1 (reflecting hepatic pyridoxal 5'-phosphate [vitamin B6] deficiency). AST and ALT levels rarely exceed 300 − 400 U/L 300-400\text{ U/L} 300 − 400 U/L . (Transaminases > 500 − 1 , 000 U/L >500-1,000\text{ U/L} > 500 − 1 , 000 U/L suggest ischemic hepatitis, toxic/acetaminophen injury, or acute viral hepatitis).
Severe Alcoholic Hepatitis: Characterized by acute jaundice, fever, tender hepatomegaly, and coagulopathy in a patient with heavy chronic alcohol intake.
Prognostic Stratification:
Maddrey Discriminant Function (DF): DF = 4.6 × [ PT patient − PT control ] + Total Bilirubin (mg/dL) \text{DF} = 4.6 \times [\text{PT}_{\text{patient}} - \text{PT}_{\text{control}}] + \text{Total Bilirubin (mg/dL)} DF = 4.6 × [ PT patient − PT control ] + Total Bilirubin (mg/dL)
Severe disease is defined as Maddrey DF ≥ 32 \text{DF} \ge 32 DF ≥ 32 OR MELD Score > 20 > 20 > 20 (predicts 30-day mortality of 30–50%).
Targeted Pharmacotherapy:
Prednisolone 40 mg PO daily for 28 days (prednisolone is preferred over prednisone because it does not require hepatic conversion).
Lille Score Assessment at Day 7: Calculate Lille score on day 7 of steroid therapy:
Lille Score < 0.45 < 0.45 < 0.45 (Responder): Continue Prednisolone to complete the 28-day course, followed by a 2–4 week taper.
Lille Score ≥ 0.45 \ge 0.45 ≥ 0.45 (Non-Responder): STOP Prednisolone immediately (steroids provide no survival benefit in non-responders and dramatically increase fatal fungal and bacterial infections).
Contraindications to Steroids: Active uncontrolled infection/sepsis, active GI hemorrhage, or acute kidney injury.