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 10 ULN. A 42-year-old asymptomatic man with AST or GPT levels of x 2-5 ULN. A 35-year-old woman with itching and an alkaline phosphatase level of x 2-4 ULN. 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 10 ULN. A 42-year-old asymptomatic man with AST or GPT levels of x 2-5 ULN. A 35-year-old woman with itching and an alkaline phosphatase level of x 2-4 ULN. 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 10 ULN. A 42-year-old asymptomatic man with AST or GPT levels of x 2-5 ULN. A 35-year-old woman with itching and an alkaline phosphatase level of x 3 ULN. 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 Tests TestHBsAgAnti-HBsAnti-HBcIgM Anti-HBc HBV 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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