Answer

B. Admit the patient to the hospital for close monitoring.

The patient has rising INR and bilirubin levels indicating the onset of liver insufficiency with the possibility of fulminant hepatitis. This requires immediate hospitalization with close neurologic assessment (for the development of encephalopathy), close monitoring of INR and for initial evaluation by a transplant team. If possible, the patient should be referred to a transplant center.

A. Continue outpatient management

Although aminotransferases are decreasing and the patient does not have encephalopathy, there is evidence of liver insufficiency with rising INR and rising bilirubin levels. This indicates the onset of fulminant liver failure and at this point outpatient management cannot be continued.

C. Start Lamivudine.

Although the patient has acute hepatitis B and lamivudine is an antiviral agent against hepatitis B, this therapy is not indicated in the acute setting.

D. Liver biopsy

A liver biopsy is not indicated in any acute hepatitis, particularly when the etiology is clear, as in this case. Perhaps the only indication for liver biopsy in the acute setting is when a treatable condition (CMV, EBV) is suspected and not confirmed by serological tests.