Evaluating the Patient With Abnormal Liver Tests-3

פרופ' צבי אקרמן מבית חולים הדסה הר הצופים

צורות של פרזנטציה בקליניקה של רופא המשפחה

• A 20 years old women with severe hepatitis[an aspartate (AST ,GOT)or alanine aminotransferase (ALT ,GPT) levels of >x 10ULN.

• A 42-year-old asymptomatic man with AST or GPT levels of x 2-5ULN.

• A 35-year-old woman with itching and an alkaline phosphatase level of x 2-4ULN.

• A obese woman with right-upper-quadrant pain and minimal aminotransferase elevation.

Acute hepatitis (ALT>10xULN)

• Viral.• Ischemic.• Toxins.• Autoimmune.• Acute Budd-Chiari.• Early phase of acute biliary obstruction.

Diagnostic tests: acute hepatitis

*HAV-IgM, HBsAg, HBc-IgM, HCV (± HCV RNA)

* Anti smooth muscle Ab, ANA, anti-LKM-1

*Ultrasound

* CMV-IgM, EBV-IgM

* Additional: toxic screen, Doppler US (hepatic

veins(

צורות של פרזנטציה בקליניקה של רופא המשפחה

• A 20 years old women with severe hepatitis[an aspartate (AST ,GOT)or alanine aminotransferase (ALT ,GPT) levels of >x 10ULN.

• A 42-year-old asymptomatic man with AST or GPT levels of x 2-5ULN.

• A 35-year-old woman with itching and an alkaline phosphatase level of x 2-4ULN.

• A obese woman with right-upper-quadrant pain and minimal aminotransferase elevation.

CLINICAL ASSESSMENT OF ABNORMAL LIVER TESTS

• Fatty liver or NASH (non alcoholic steatohepatitis) (DM II, BP , obesity, insulin resistance).

• Chronic viral hepatitis (HBV, HCV).

• Alcoholic liver disease (AST>ALT, MCV , GGT ) .

• • Autoimmune hepatitis (ANA, aSMA, LKM-1).

• Wison’s disease (age < 55) (hemochromatosis, A1AT).

• Drug induced liver injury.

• Celiac disease, Addison.

Diagnostic tests : asymptomatic abnormal LT (X2-5)

* Viral serology: HBsAg, HCV.

* Autoimmune screen: anti-smooth muscle Ab,

ANA, anti-LKM-1, (anti mitochondrial).

* Metabolic (age < 50): ceruloplasmin, ferritin,

transferin, iron, α1 anti-trypsin.

* NAFLD: lipids, HbA1c, insulin resistance, glucose.

* US.

* Additional: celiac (anti-transglutaminase, endomysial).

צורות של פרזנטציה בקליניקה של רופא המשפחה

• A 20 years old women with severe hepatitis[an aspartate (AST ,GOT)or alanine aminotransferase (ALT ,GPT) levels of >x 10ULN.

• A 42-year-old asymptomatic man with AST or GPT levels of x 2-5ULN.

• A 35-year-old woman with itching and an alkaline phosphatase level of x 3ULN.

• A obese woman with right-upper-quadrant pain and minimal aminotransferase elevation.

A patient with cholestatic liver cell abnormalities

ULTRASOUND (± CT): dilated vs. non-dilated ducts.

Extra-hepatic obstruction (stones, neoplasm, stricture).

PBC (anti-mitochondrial Ab, IgM).

PSC (IBD-UC, ANCA, ERCP, MRCP).

Infiltrative disease (neoplastic, amyloidosis ).

Granulomatous disease (sarcoidosis, TB, Q fever).

Granulomatous hepatitis.

Drug induced cholestatic liver injury (ACE-I, NSAIDs).

Fatty liver (GGT-DM).

Interpretation of Diagnostic TestsTestHBsAgAnti-HBsAnti-HBcIgM

Anti-HBcHBV DNA

Acute infection, high infectivity

+-+++

Recovery from infection

-++--

Immunization-+---

Chronic infection+-+-+/-

Unclear*--+--

*4 possibilities: 1) resolved infection (most likely), 2) false-positive anti-HBC, 3) “low level” chronic infection, 4) resolving acute infection.

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