evaluating the patient with abnormal liver tests-2 פרופ ' צבי אקרמן מבית...
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Evaluating the Patient With Abnormal Liver Tests-2
פרופ' צבי אקרמן מבית חולים הדסה הר הצופים
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Imaging studies
• Abdominal Ultrasound with Doppler of hepatic and portal veins
• Abdominal MRCP
• Upper endoscopy (EGD)
• Liver biopsy
• Non Invasive Tests for Fibrosis
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Imaging studies-1
• Abdominal Ultrasound with Doppler of hepatic and portal veins-1
• Abdominal ultrasound is helpful in the evaluation of patients with cirrhosis.
• It may reveal a shrunken, nodular liver suggestive of cirrhosis.
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Imaging studies-1a1a
• The liver may appear echogenic if excessive fat has infiltrated the liver as in NAFLD (nonalcoholic fatty liver disease).
• It is sensitive for the detection of small to moderate amounts of ascites.
• It can be used to screen for liver masses which may suggest the presence of hepatocellular carcinoma.
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Imaging studies-2
• Abdominal Ultrasound with Doppler of hepatic and portal veins-2
• The use of Doppler ultrasonography can provide information about the hepatic and portal veins such as portal vein thrombosis.
• Because it is relatively inexpensive, and widely available, ultrasonography is the preferred initial imaging modality in patients with cirrhosis.
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Imaging studies-3
• Abdominal MRCP
• MRI is not indicated in every evaluation of liver disease , only in cases where specific bile duct pathology is suspected.
• It is expensive and ‘simple”information can be obtained with ultrasonography.
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Imaging studies-4
• Upper endoscopy (EGD)
• Upper endoscopy is useful in the diagnosis of esophageal varices, a finding seen with portal hypertension.
• In cirrhotic patients, it is useful to document the presence of varices so prophylactic measures can be instituted to decrease the risk of bleeding.
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Imaging studies-3
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Imaging studies-3
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Imaging studies • Abdominal Ultrasound with Doppler of hepatic and
portal veins
• Abdominal MRCP
• Upper endoscopy (EGD)
• Liver fibrosis Assessment :Liver biopsy
• Liver fibrosis Assessment :Non Invasive Tests for Fibrosis
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Liver Biopsy
Hepatic Injury : Hepatic Injury : necrotico-inflammatory activity, necrotico-inflammatory activity, fibrosis, fibrosis, steatosis, steatosis, biliary lesions, vascular lesionsbiliary lesions, vascular lesions
Fibrosis scores Fibrosis scores ( METAVIR, Knodell , Ishak,…)( METAVIR, Knodell , Ishak,…)
Invasive procedure Invasive procedure morbidity : 0.3 to 0.6% morbidity : 0.3 to 0.6% mortality : 0 to 0.05% mortality : 0 to 0.05%
Cost : approximately 4000 NIS ( without complications)Cost : approximately 4000 NIS ( without complications)
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F1
F4
F2
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F1
F4
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Imaging studies
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BioMarkers of liver injury
• Markers of Fibrosis
• Scores of Fibrosis
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Hem orrhage Liver Failure Cancer
F4
F3
F2
F1
F0
Fibrotic LiverDisease
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How must be an ideal marker of liver Fibrosis?
• Specific to the Liver
• Independant to metabolic dysfunction
• Easy to perform
• Sensitivity to detect the different stages of liver fibrosis
• Can reliably assess the efficacy of antifibrotic treatment
• Can be used whatever the etiology of chonic liver fibrosis
• Non influenced by extra-hepatic factors
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Haptoglobin
Alpha2Macroglobulin
Apolipoprotein A1
Total Bilirubin
Gamma GT
In Situ In Serum: FibroTestIn Serum: FibroTest
Liver InjuryLiver Injury
Activated Stellate CellsActivated Stellate Cells
Fibrotic MatrixFibrotic Matrix
ALT
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0.00
0.10
0.20
0.30
0.40
0.50
0.60
0.70
0.80
0.90
1.00
0 1 2 3 4
FibroTest
METAVIR Fibrosis Stage
Multicenter Independant ValidationHalfon, Am J Gastroenterol 2006
n=519
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0.00
0.25
0.50
0.75
1.00
0 1 2 3 4
Fibrosis Stage
Fib
rote
stDisease
HBVHCVHCV_HIVNAFLDOH
Myers et al 2003
Poynard et al 2004
Myers et al 2003
Ratziu et al 2004
Naveau et al 2005
FibroFibroTestTest: fibrosis marker in other chronic : fibrosis marker in other chronic liver diseases (n=2,706)liver diseases (n=2,706)
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LONGITUDINAL STUDIES
The Fibrotest was found to predict the evolution of HCV patients towards cirrhosis better than liver biopsy after 5 years of follow-upNgo Clin Chem 2006
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Progression of liver fibrosis
0
1
2
3
4
0 10 20 30 40 50
F METAVIR
Duration in years
Rapid Intermediate
Slow fibroser
Poynard et al
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Abnormal Liver Test Results: Points for Clinical Practice• Abnormal liver test results will be identified in 8%-20% of patients during
clinical care.
• Most patients with abnormal liver test results should have additional evaluation. A referral to the gastroenterologist may be needed.
• A careful history and physical examination frequently provide the diagnosis, obviating the need for invasive testing.
• If there are signs or symptoms of chronic liver disease, considering the patient's age may assist in the diagnosis.
• Isolated elevation of GGT occurs and a cause may not be identified.
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CON-Abnormal Liver Test Results: Points for Clinical Practice
• The presence of multiple abnormal test results makes significant liver disease more likely.
• Aminotransferase, alkaline phosphatase, and GGT levels can be elevated from causes other than liver disease.
• Persisting abnormalities of aminotransferases or enzymes of cholestasis should be further evaluated because up to two thirds will have a diagnosis requiring follow-up or intervention.
• Supplemental testing with additional laboratory tests, ultrasonography, or magnetic resonance cholangiography should be considered when the diagnosis is unclear or confirmation of liver disease diagnosis is required.
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תודה רבה על ההקשבה