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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. 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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  1. Evaluating the Patient With Abnormal Liver Tests-3 פרופ' צבי אקרמן מבית חולים הדסה הר הצופים

  2. 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.

  3. Acute hepatitis (ALT>10xULN) • Viral. • Ischemic. • Toxins. • Autoimmune. • Acute Budd-Chiari. • Early phase of acute biliary obstruction.

  4. 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)

  5. 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.

  6. 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.

  7. 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).

  8. 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.

  9. 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).

  10. 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.

  11. תודה על ההקשבה

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