Evaluating the Patient With Abnormal Liver Tests-3
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Transcript of Evaluating the Patient With Abnormal Liver Tests-3
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.