Evaluating the patient with abnormal liver tests 3
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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 .

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Evaluating the Patient With Abnormal Liver Tests-3

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Evaluating the patient with abnormal liver tests 3

Evaluating the Patient With Abnormal Liver Tests-3

פרופ' צבי אקרמן מבית חולים הדסה הר הצופים


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

Acute hepatitis (ALT>10xULN)

  • Viral.

  • Ischemic.

  • Toxins.

  • Autoimmune.

  • Acute Budd-Chiari.

  • Early phase of acute biliary obstruction.


Diagnostic tests acute hepatitis

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)


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.


Clinical assessment of abnormal liver tests

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

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).


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 3ULN.

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


A patient with cholestatic liver cell abnormalities

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

Interpretation of Diagnostic Tests

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


Evaluating the patient with abnormal liver tests 3

תודה על ההקשבה


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