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Liver Function Tests in Alcoholic Liver Disease
- The disproportionate elevation of AST levels is the most typical biochemical pattern in these patients.
- At the same time, an elevated AST/ALT ratio (more than 2.0) is quite specific because it is rarely seen in other forms of liver disease (e.g., viral hepatitis or ischemic liver injury).
- The relatively lower elevation of serum ALT levels has been ascribed to hepatic deficiency of pyridoxal 6-phosphate in alcoholics, which is a cofactor for the enzymatic activity of AL T; therefore, the increased AST/ALT ratio is generally attributed to failure to appropriately increase the ALT levels, rather than a disproportionate elevation in AST levels.
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Autoimmune hepatitis
- It causes progressive parenchymal liver damage.
- Its course is variable, and severe cases can progress to cirrhosis and liver failure in 6 months.
- Most cases occur in young to middle-aged women. Autoimmune manifestations such as arthritis, erythema nodosum, thyroiditis, pleurisy, pericarditis, anemia and sicca syndrome are common.
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Investigation of Autoimmune Hepatitis
- Common findings include elevated AST and ALT levels, a normal or near-normal alkaline phosphatase level, and a normal bilirubin level.
- Autoantibodies are common, and the most typical are antinuclear antibodies (in a homogeneous staining pattern, hence the term "lupoid hepatitis") and anti smooth muscle antibodies (against actin).
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Primary biliary cirrhosis (PBC)
- It is a chronic and progressive autoimmune liver disease .
- Most patients (90%) are women, and disease onset is usually between 30 and 65 years of age.
- Its major pathological feature is the destruction of small- and mid-sized bile ducts. There is progressive fibrosis, and end-stage liver disease can supervene 5 to 10 years after the diagnosis.
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Clinical Features of PBC
Signs and symptoms include progressive jaundice, steatorrhea, fatigue (an early and sometimes debilitating symptom), hyperlipidemia with formation of xanthomas, bone disease (osteoporosis and/or osteomalacia), hyperpigmentation of exposed areas and autoimmune manifestations such as keratoconjunctivitis sicca, CREST syndrome, type 1 diabetes, rheumatoid arthritis and antithyroid antibodies.
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Investigation of PBC
- Antimitochondrial antibodies (AMA) have high sensitivity (more than 90%) and 98% specificity for PBC.
- Diagnostic confirmation requires liver biopsy.
- This procedure can also give information about disease stage and prognosis.
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Treatment options for active PBC
- It include ursodeoxycholic acid and liver transplantation.
- Steroids and immunosuppressive drugs aren't useful, despite the disease's apparently autoimmune nature.
- Ursodeoxycholic acid can slow the progression of PBC, improve overall survival and maybe transplantation-free survival.
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Bone Disease in PBC
- Osteomalacia and osteoporosis are important complications of long-standing cholestatic disease, and of PBC in particular.
- Screening with bone densitometry, calcium supplementation and eventual treatment with vitamin D and/or bisphosphonates are essential in these patients follow-up.
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Acute hepatitis C infection
- It is frequently asymptomatic but can present with malaise, nausea, right upper quadrant pain, and liver function test abnormalities.
- It is important to maintain a high degree of suspicion for hepatitis C in patients with risk factors.
- Because anti-HCV antibodies are frequently negative during the acute phase of infection, testing for HCV RNA may be necessary.
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MELD score
- The Model for End-stage Liver Disease (MELD) scoring system is preferred to the Child-Turcotte Pugh scoring system for determining prognosis in patients with chronic liver disease.
- It is also the scoring system used to determine allocation of liver transplants and whether or not TIPS should be performed.
- The MELD score can be calculated using the following formula: 3.8[ serum bilirubin (mg/dL)] + 11.2[INR] +9.6 [serum creatinine (mg/dL)] +6.4.
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Hepatitis A and B Vaccine
- Hepatitis A vaccine should be given to all unimmunized patients with underlying chronic liver disease.
- Hepatitis B vaccine is recommended in all unimmunized patients with chronic liver disease, including chronic hepatitis C.
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Treating Hepatitis C Infection
Patients with chronic hepatitis C having HCV RNA positive, consistently elevated ALT, and at least moderate inflammation on liver biopsy should be treated with interferon and ribavirin.
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Hemochromatosis
- It is a autosomal recessive genetic disorders.
- It results in the excessive accumulation of iron in parenchymal organs.
- It can ultimately manifest as liver disease, skin pigmentation, diabetes mellitus, arthropathy, impotence, or cardiac enlargement.
- Symptoms are often present for ten years or more before the diagnosis is made.
- The classic triad of cirrhosis, diabetes mellitus, and skin pigmentation ("bronze diabetes") is a late finding that occurs when the total body iron content is 20 grams or more.
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Treatment of Hemochromatosis
- The preferred means of treating hemochromatosis is therapeutic phlebotomy, which entails the removal of approximately one unit of blood each week until iron stores normalize.
- Patients with a normal ALT level and/or mild inflammation without fibrosis on liver biopsy can be observed closely.
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Management of Hepatic Adenoma
- Small (less than 5cm) and asymptomatic lesions are usually managed with discontinuation of OCPs.
- Malignancy should be suspected if the tumor increases in size even after discontinuation of OCPs, or if the AFP level is increased.
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Complications of Hepatic Adenoma
Main complications of hepatic adenoma are sudden rupture with intra-abdominal bleeding and malignant transformation.
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Isolated anti HBC antibody elevation
- Patients with an isolated elevated level of anti HBc antibody should have a repeat Hepatitis B panel checked to rule out a false positive result, followed by a measurement of anti HBc lgM and liver function tests to determine the acuity of the infection.
- These tests are helpful since anti HBc may be the only positive result in the Hepatitis B panel in a patient with acute infection during the "window period."
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