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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

Evaluating the Patient With Abnormal Liver Tests-3

פרופ' צבי אקרמן מבית חולים הדסה הר הצופים

slide2
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)

slide17
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).

slide21
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.

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