The nature of unexplained chronic aminotransferase elevations of a mild to moderate degree in asymptomatic patients

Approach to the Liver Biopsy in the Patient With Chronic Low-Level Aminotransferase Elevations

Pathologists sometimes encounter a liver biopsy from an asymptomatic patient with unexplained low-level parenchymal liver enzyme elevations. These biopsies often have minor histologic changes but are otherwise almost entirely normal. This can lead to the quandary of whether or not the features are clinically meaningful and how one must formulate a diagnosis from the possibly nonspecific findings of a near-normal biopsy. The following discussion focuses on the histologic changes that can be seen in these biopsies and the practical issues involved in making a diagnosis that provides useful information to the clinician. The literature and textbooks addressing the histologic and clinical features of these cases are reviewed with an emphasis on the clinical implications of finding nonspecific histologic alterations in these patients.

Elevated Liver Enzymes in Asymptomatic Patients - What Should I Do?

Elevated liver enzymes are a common scenario encountered by physicians in clinical practice. For many physicians, however, evaluation of such a problem in patients presenting with no symptoms can be challenging. Evidence supporting a standardized approach to evaluation is lacking. Although alterations of liver enzymes could be a normal physiological phenomenon in certain cases, it may also reflect potential liver injury in others, necessitating its further assessment and management. In this article, we provide a guide to primary care clinicians to interpret abnormal elevation of liver enzymes in asymptomatic patients using a step-wise algorithm. Adopting a schematic approach that classifies enzyme alterations on the basis of pattern (hepatocellular, cholestatic and isolated hyperbilirubinemia), we review an approach to abnormal alteration of liver enzymes within each section, the most common causes of enzyme alteration, and suggest initial investigations.

Request of laboratory liver tests in primary care in Spain: potential savings if appropriateness indicator targets were achieved

AIMS

Liver laboratory tests are used to screen for liver disease, suggest the underlying cause, estimate the severity, assess prognosis, and monitor the efficacy of therapy. The aim of this study was to compare the liver laboratory tests requesting patterns by GPs in Spain, according to geographic and hospital characteristics, to investigate the degree of requesting appropriateness.

MATERIALS AND METHODS

One hundred and forty-one clinical laboratories were invited to participate from diverse regions across Spain. They filed out the number of laboratory liver tests requested by GPs for the year 2012. Two types of appropriateness indicators were calculated: every test request per 1000 inhabitants or ratios of related tests requests. The indicator results obtained were compared between the different hospitals, according to their setting, location, and management. The savings generated, if each area would have achieved indicator targets, were calculated.

RESULTS

We recruited 76 laboratories covering a population of 17,679,195 inhabitants. GPs requested 20,916,780 laboratory liver tests in the year 2012. No differences were obtained according to their setting. Lactate dehydrogenase and direct bilirubin per 1000 inhabitants were significantly higher in institutions with private management. Largest differences were observed between communities. Nine, 31, 0, and 13 laboratories, respectively, achieved the aspartate aminotransferase, lactate dehydrogenase, γ-glutamyl transpeptidase, and total bilirubin-related alanine aminotransferase indicator targets. Reaching ratios would have resulted in savings of €1,028,468.

CONCLUSION

There was a high variability in the request of liver tests. This emphasizes the need to implement interventions to improve appropriate use of liver tests.

To biopsy or not to biopsy: evaluation of a large German cohort of patients with abnormal liver tests of unknown etiology

BACKGROUND AND AIMS

Despite increasingly sensitive and accurate blood tests to detect liver disease, liver biopsy remains very useful in patients with atypical clinical features and abnormal liver tests of unknown etiology. The aim was to determine those elevated laboratory liver parameters that cause the clinician to order a biopsy, and whether laboratory tests are associated with pathological findings on histology.

METHODS

504 patients with unclear hepatopathy, admitted to the outpatient clinic of a university hospital between 2007 and 2010, were analyzed with respect to laboratory results, clinical data, and the results of liver biopsies.

RESULTS

Aspartate aminotransferase (AST) and glutamate dehydrogenase (GLDH) levels above the normal range significantly increased the likelihood of recommending a liver biopsy by 81% [OR with 95% CI 1.81 (1.21-2.71), p = 0.004] and 159% [OR with 95% CI 2.59 (1.70-3.93), p < 0.001], respectively. AST values above normal were associated with fibrosis (63 vs. 40% for normal AST, p = 0.010). Elevated ferritin levels pointed to a higher incidence of steatosis (48 vs. 10% for normal ferritin, p < 0.001) and inflammation (87 vs. 62% for normal ferritin, p = 0.004).

CONCLUSIONS

Our results indicate that elevated AST and GLDH were associated with a greater likelihood of recommending liver biopsy. Elevated AST and ferritin levels were associated with steatosis, inflammation and fibrosis on liver biopsies. Thus, AST and ferritin may be useful non-invasive predictors of liver pathology in patients with unclear hepatopathy.

A systematic review of the prevalence of mildly abnormal liver function tests and associated health outcomes

Liver function tests (LFTs) are commonly performed to investigate asymptomatic individuals or those with nonspecific symptoms. Understanding the prevalence of mildly abnormal LFTs in the general population and the prevalence of liver disease following abnormal LFTs has important implications for the planning of care pathways and the provision of healthcare services. A systematic review of the literature on the prevalence of abnormal LFTs in the general population and their respective health outcomes was conducted. A total of 37 studies reporting data on the prevalence of abnormal LFTs (published between 2000 and 2014) were identified from online database searches or were manually selected from article bibliographies. The prevalence of mildly abnormal LFTs, with one or more abnormal constituents in the LFT, was high at 10-21.7%. The prevalence of severe liver disease within cohorts with abnormal LFTs is relatively low (<5%), and a large proportion of abnormal LFTs remains unexplained. Among individuals with unexplained abnormal LFTs, risk factors include obesity and insulin resistance. Common aetiologies for abnormal LFTs were non-alcohol-related fatty liver disease (NAFLD), followed by alcohol use and viral infections. In addition, normal LFTs do not rule out liver disease. The prevalence of abnormal LFTs depends on the definition and population but is likely to be between 10 and 20% in the general population. Abnormal LFTs are associated with a range of health outcomes but are not necessarily strongly diagnostic of severe liver pathology. Important areas of future research include further studies on the prevalence and predictive ability of LFTs in large, population-representative samples.

Acute liver injury in two workers exposed to chloroform in cleanrooms: a case report

We report 2 cases of hepatotoxicity in cleanroom workers due to high retained chloroform air concentrations. The women, aged 34 and 41 years, who had been working in a medical endoscopic device manufacturer as cleanroom workers for approximately 40–45 days suffered severe liver damage. Two measured time-weighted averages of the chloroform concentration in the air in the cleanroom were 82.74 and 64.24 ppm, which are more than 6 times the legal occupational exposure limit in Korea. Only 7% of the cleanroom air was newly introduced from outside. The clinical courses of these cases and workplace inspection, led us to conclude that both cases of hepatotoxicity were caused by chloroform exposure.

The natural history of autoimmune hepatitis presenting with jaundice

BACKGROUND

Forty percent of patients with autoimmune hepatitis (AIH) present with acute jaundice/hepatitis. Such patients, when treated promptly, are thought to have a good prognosis.

OBJECTIVES

The objective of this study was to describe the natural history of AIH in patients presenting with jaundice/hepatitis and to determine whether the diagnosis could have been made earlier, before presentation.

METHODS

This study is a retrospective review of 2249 consecutive patients who presented with jaundice to the Jaundice Hotline clinic, Truro, Cornwall, UK, over 15 years (1998-2013) and includes a review of the laboratory data over a 23-year period (1990-2013).

RESULTS

Of the 955 patients with hepatocellular jaundice, 47 (5%) had criterion-referenced AIH: 35 female and 12 male, the median age was 65 years (range 15-91 years); the bilirubin concentration was 139 μmol/l (range 23-634 μmol/l) and the alanine transaminase level was 687 IU/l (range 22-2519 IU/l). Among the patients, 23/46 (50%) were cirrhotic on biopsy; 11/47 (23%) died: median time from diagnosis to death, 5 months (range 1-59); median age, 72 years (range 59-91 years). All 8/11 patients who died of liver-related causes were cirrhotic. Weight loss (P=0.04) and presence of cirrhosis (P=0.004) and varices (P=0.015) were more common among those who died. Among patients who died from liver-related causes, 6/8 (75%) died less than 6 months from diagnosis. Cirrhosis at presentation and oesophageal varices were associated with early liver-related deaths (P=0.011, 0.002 respectively). Liver function test results were available in 33/47 (70%) patients before presentation. Among these patients, 16 (49%) had abnormal alanine transaminase levels previously, and eight (50%) were cirrhotic at presentation.

CONCLUSION

AIH presenting as jaundice/hepatitis was mainly observed in older women: 50% of the patients were cirrhotic, and liver-related mortality was high. Some of these deaths were potentially preventable by earlier diagnosis, as the patients had abnormal liver function test results previously, which had not been investigated.

Surgery in patients with portal hypertension: a preoperative checklist and strategies for attenuating risk

Patients with liver disease and portal hypertension are at increased risk of complications from surgery. Recent advances have allowed better optimization of patients with cirrhosis before surgery and a reduction in postoperative complications. Despite this progress, the estimation of surgical risk in a patient with cirrhosis is challenging. The MELD score has shown promise in predicting postoperative mortality compared with the Child-Turcotte-Pugh score. This article addresses current concepts in the perioperative evaluation of patients with liver disease and portal tension, including a preoperative liver assessment (POLA) checklist that may be useful towards mitigating perioperative complications.

Liver test results do not identify liver disease in adults with α(1)-antitrypsin deficiency

BACKGROUND & AIMS

Liver disease is a significant cause of death among adults with α(1)-antitrypsin (A-AT) deficiency. Age and male sex are reported risk factors for liver disease. In the absence of adequate risk stratification, current recommendations are to intermittently test A-AT-deficient adults for liver function. We evaluated this recommendation in a large group of adults with A-AT deficiency to determine the prevalence of increased levels of alanine aminotransferase (ALT) and identify risk factors for liver disease.

METHODS

We used the Alpha-1 Foundation DNA and Tissue Bank to identify a cross section of A-AT-deficient adults (n = 647) with and without liver disease; individuals without A-AT deficiency were used as controls (n = 152). Results from ALT tests were compared between groups.

RESULTS

The prevalence of liver disease among individuals with A-AT deficiency was 7.9%; an increased level of ALT was observed in 7.8% of A-AT-deficient individuals, which did not differ significantly from controls. Mean levels of ALT fell within normal range for all groups. An increased level of ALT identified patients with liver disease with 11.9% sensitivity. The level of only γ-glutamyl transpeptidase was significantly higher in the A-AT-deficient group than in controls (43 vs 30 IU/mL; P < .003). A childhood history of liver disease and male sex were risk factors for adult liver disease in the multivariate analysis.

CONCLUSIONS

An increased level of ALT does not identify adults with A-AT deficiency who have liver disease. Male sex and liver disease during childhood might help identify those at risk.

Systematic review: managing suboptimal treatment responses in autoimmune hepatitis with conventional and nonstandard drugs

BACKGROUND

Corticosteroid treatment for autoimmune hepatitis has been shown by randomised controlled clinical trials to ameliorate symptoms, normalise liver tests, improve histological findings and extend survival. Nevertheless, suboptimal responses to corticosteroid treatment still occur.

AIM

To describe the current definitions, frequencies, clinical relevance and treatment options for suboptimal responses, and to discuss alternative medications that have been used off-label for these occurrences.

METHODS

Literature search was made for full-text papers published in English using the keyword 'autoimmune hepatitis'. Authors' personal experience and investigational studies also helped to identify important contributions to the literature.

RESULTS

Suboptimal responses to standard therapy include treatment failure (7%), incomplete response (14%), drug toxicity (13%) and relapse after drug withdrawal (50-86%). The probability of a suboptimal response prior to treatment is higher in young patients and in patients with a severe presentation, jaundice, high MELD score at diagnosis, multilobular necrosis or cirrhosis, antibodies to soluble liver antigen, or inability to improve by clinical indices within two weeks or by MELD score within 7 days of conventional corticosteroid treatment. Management strategies have been developed for the adverse responses and nonstandard drugs, including mycophenolate mofetil, budesonide, ciclosporin, tacrolimus, sirolimus and rituximab, are emerging as rescue therapies or alternative frontline agents.

CONCLUSIONS

Once diagnosed, the suboptimal response should be treated by a highly individualised and well-monitored regimen, preferentially using first-line therapy. Nonstandard drugs warrant consideration as salvage or second-line therapies.

Liver biopsy in modern clinical practice: a pediatric point-of-view

Liver biopsy remains the foundation of evaluation and management of liver disease in children, although the role of the liver biopsy is changing with development of alternative methods of diagnosis and advancement of hepatic imaging techniques. The indications for liver biopsy are evolving as current knowledge of etiologies, noninvasive biomarker alternatives, and treatment options in pediatric liver disease are expanding. The procedure can often be complicated in children by technical difficulties, cost, and smaller specimen size. Communication and partnership of clinicians with pathologists experienced in pediatric liver diseases are essential. DNA sequencing, novel imaging modalities, noninvasive biomarkers of fibrosis and apoptosis, proteomics, and genome-wide association studies offer potential alternative methods for evaluation of liver disease in children. This review presents specific indications, considerations, methods, complications, contraindications, and alternatives for pediatric liver biopsy.

Probability of C282Y homozygosity decreases as liver transaminase activities increase in participants with hyperferritinemia in the hemochromatosis and iron overload screening study

Hemochromatosis is considered by many to be an uncommon disorder, although the prevalence of HFE (High Iron) 282 Cys → Tyr (C282Y) homozygosity is relatively high in Caucasians. Liver disease is one of the most consistent findings in advanced iron overload resulting from hemochromatosis. Liver clinics are often thought to be ideal venues for diagnosis of hemochromatosis, but diagnosis rates are often low. The Hemochromatosis and Iron Overload Screening (HEIRS) Study screened 99,711 primary care participants in North America for iron overload using serum ferritin and transferrin saturation measurements and HFE genotyping. In this HEIRS substudy, serum hepatic transaminases activities (e.g., alanine aminotransferase [ALT] and aspartate aminotransferase [AST]) were compared between 162 C282Y homozygotes and 1,367 nonhomozygotes with serum ferritin levels >300 μg/L in men and >200 μg/L in women and transferrin saturation >45% in women and 50% in men. The probability of being a C282Y homozygote was determined for AST and ALT ranges. Mean ALT and AST activities were significantly lower in C282Y homozygotes than nonhomozygotes. The probability of being a C282Y homozygote increased as the ALT and AST activities decreased.

CONCLUSION

Patients with hyperferritinemia are more likely to be C282Y homozygotes if they have normal liver transaminase activities. This paradox could explain the low yields of hemochromatosis screening reported by some liver clinics.

Cryptogenic chronic hepatitis and its changing guise in adults

Cryptogenic chronic hepatitis is a disease that is unexplained by conventional clinical, laboratory and histological findings, and it can progress to cirrhosis, develop hepatocellular carcinoma, and require liver transplantation. The goals of this review are to describe the changing phenotype of cryptogenic chronic hepatitis in adults, develop a diagnostic algorithm appropriate to current practice, and suggest treatment options. The frequency of cryptogenic hepatitis is estimated at 5.4%. Cryptogenic cirrhosis is diagnosed in 5-30% of patients with cirrhosis, and it is present in 3-14% of adults awaiting liver transplantation. Nonalcoholic fatty liver disease has been implicated in 21-63% of patients, and autoimmune hepatitis is a likely diagnosis in 10-54% of individuals. Viral infections, hereditary liver diseases, celiac disease, and unsuspected alcohol or drug-induced liver injury are recognized infrequently in the current cryptogenic population. Manifestations of the metabolic syndrome heighten the suspicion of nonalcoholic fatty liver disease, and the absence of hepatic steatosis does not discount this possibility. The diagnostic scoring system of the International Autoimmune Hepatitis Group can support the diagnosis of autoimmune hepatitis in some patients. Certain genetic mutations may have disease-specificity, and they suggest that some patients may have an independent and uncharacterized disease. Corticosteroid therapy is effective in patients with autoimmune features, and life-style changes and specific therapies for manifestations of the metabolic syndrome are appropriate for all obese patients. The 1- and 5-year survivals after liver transplantation have ranged from 72-85% to 58-73%, respectively.

Large-scale population analysis reveals an extremely low threshold for "non-healthy" alanine aminotransferase that predicts diabetes mellitus

BACKGROUND AND AIMS

Serum alanine aminotransferase (ALT) is commonly used to detect liver damage. Recent studies indicate that ALT levels at the upper range of normal limits are predictors of adverse outcomes, especially diabetes mellitus (DM) and the metabolic syndrome. The aim of our study was to define the ALT threshold for both men and women that may predict the onset of DM.

METHODS

We analyzed a large Health Maintenance Organization cohort of 157 308 healthy subjects with no evidence of liver disease and with baseline ALT levels ≤ 120 U/L, and identified those who developed DM within 6 years.

RESULTS

Overall, an elevated baseline serum ALT value was significantly associated with the development of DM, with an odds ratio of 3.3 when comparing the higher and the lower quartiles of the whole study population. A subgroup analysis revealed that baseline ALT values higher than 10 U/L among women and 22 U/L among men were already significantly associated with an increased risk for DM for any increment in ALT level. Notably, ALT values higher than ∼55 U/L were associated with increased risk for DM that was relatively constant for any increment in ALT. Higher baseline ALT levels were stronger predictors for DM as compared with age, triglycerides and cholesterol levels.

CONCLUSION

Our study implies that ALT values higher than 10 U/L and 22 U/L for women and men, respectively, may predict DM. We suggest redefining ALT values as either 'normal' or 'healthy', with the later reflecting much lower values, above which an individual is at increased risk for DM.

Re-evaluation of the serum alanine aminotransferase upper normal limit in chronic hepatitis C patients

OBJECTIVE

The aim of this study was to re-evaluate the upper limit of normal range (ULN) for serum alanine aminotransferase (ALT) in chronic hepatitis C (CH-C) patients who achieved sustained virological response (SVR) to interferon therapy.

METHODS

Enrolled in this study were 136 consecutive patients, 84 males and 52 females, mean age 52.1+/-14.8 years, with CH-C who received interferon therapy during 1992 to 2008 and achieved SVR. AST and ALT levels (3 serial measurements) were measured every 3 to 4 months over one year after termination of interferon therapy and then the measurements were averaged for each patient.

RESULTS

The distribution of AST and ALT showed normal distribution. Overall, AST levels were 19.7+/-3 IU/L and ALT levels were 13.8+/-3.1 IU/L in all patients, AST levels were 19.8+/-3 IU/L and 12.9+/-2.9 IU/L and ALT levels were 14.4+/-3.2 IU/L and 9.9+/-3.5 IU/L in male and female patients, respectively. AST level was the highest in the 6th decade and ALT level was in the 5th decade.

CONCLUSION

In this study on CH-C patients with SVR to interferon therapy, ULN of serum ALT and AST were far lower than the current accepted value. We propose that a suitable ULN of serum AST is <25 IU/L and ALT is <20 IU/L in CH-C patients.

Preoperative risk assessment for patients with liver disease

Patients with underlying liver disease often present for non-liver-related surgery and are at risk for postoperative decompensation. Several predictive models exist to determine the risk of morbidity and mortality after surgery in such patients, but the risk depends on the severity of liver disease and also the type and urgency of the surgery. Clinicians should be cognizant of the various risk assessment tools and incorporate them into their practice when encountering patients with liver disease undergoing surgery.

Reexamining transaminase elevation in Phase I clinical trials: the importance of baseline and change from baseline

PURPOSE

The aims of the present analysis were to determine prevalence of transaminase elevation in placebo-treated healthy volunteers in our historical phase I clinical trials and to assess which factors were associated with it.

METHODS

We performed a retrospective analysis of alanine transaminase (ALT) levels in 481 placebo-treated healthy volunteers from 20 phase I trials by examining ALT elevation rates using the upper limit of normal values (ULN) as the cutoff as well as changes from baseline in actual ALT values.

RESULTS

The ULN for ALT ranged from 32 to 72 IU/L across the studies. Although the overall ALT elevation rate (4.4%) from pooled datasets was low, the elevation rates were higher in more recent studies than in earlier ones. While elevation rates at baseline and during placebo treatment did not differ significantly, ALT maximal levels during placebo treatment were significantly higher than baseline levels. Moreover, baseline ALT levels were found to be more important in predicting ALT elevation during placebo treatment than demographic and study design factors.

CONCLUSION

Baseline level and changes from baseline in transaminase are important variables to examine in addition to elevation above ULN for more reliably interpreting liver signals in Phase I clinical trials.

Liver disease in adolescents: A cohort study of high-risk individuals

Little is known about the health and behavior of adolescent offenders as they relate to abnormalities of liver biochemistry and hepatitis C virus (HCV) infection. A large study of male juvenile offenders was undertaken that allowed a re-evaluation of the normal limits of alanine aminotransferase (ALT), associations with elevated ALT, and HCV antibody positivity. Young offenders (age 12-19 years) serving community orders participated in a wide-ranging health survey and laboratory assessment between October 2003 and December 2005. Normal ranges for liver biochemistry were calculated from the 95th percentile of males at the lowest risk for liver disease. The final sample comprised 682 males, of whom 439 (64%) gave blood. The calculated upper limit of normal for ALT was 28 IU/L. Seventeen percent of adolescents had an elevated ALT. Strong associations with elevated ALT included HCV antibody positivity [odds ratio (OR) 14.6], overweight and obesity (OR 6.9), and elevated total cholesterol (OR 3.6). More than 90% of adolescents with elevated ALT levels had 1 or more features of the metabolic syndrome. HCV antibody was positive in approximately 3% of the cohort, with the most significant risk factor being injecting drug use (OR 7.8; P < 0.01). The new infection rate was 3.7% per year.

CONCLUSION

New upper limits for ALT provide greater sensitivity for the early diagnosis of liver disease in adolescents. High rates of HCV infection and obesity-related liver disease exist in this group, and targeted interventions are needed to reduce future health-related morbidity.

Features associated with treatment failure in type 1 autoimmune hepatitis and predictive value of the model of end-stage liver disease

Autoimmune hepatitis may fail to respond to corticosteroid therapy, but the frequency and bases for this outcome are uncertain. We aimed to determine the frequency and nature of treatment failure in patients with type 1 autoimmune hepatitis, define features associated with its occurrence, and assess if the model for end-stage liver disease can predict this outcome. Patients failing conventional corticosteroid regimens were compared to patients who responded to similar regimens. Fourteen of 214 patients (7%) failed corticosteroid treatment. Patients who failed therapy were younger (33 +/- 3 years versus 48 +/- 1 years, P = 0.0008), had higher serum levels of bilirubin at accession (4.1 +/- 0.9 mg/dL versus 2.3 +/- 0.2 mg/dL, P = 0.02), presented acutely more frequently (43% versus 14%, P = 0.01), and had a higher frequency of HLA (human leukocyte antigen) DRB1*03 (93% versus 53%, P = 0.004) than did patients who achieved remission. An alternative disease (fatty liver disease) emerged in only 1 patient who failed therapy (7%). Scores determined by the model of end-stage liver disease at presentation of patients who failed treatment were higher than those of who achieved remission (16 +/- 1 versus 10 +/- 0.3 points, P < 0.0001), and score greater than 12 points had greater sensitivity (97%) and specificity (68%) for treatment failure than did HLA DRB1*03 or other features.

CONCLUSION

Onset at an early age, acute presentation, hyperbilirubinemia, and presence of HLA DRB1*03 characterize patients who fail corticosteroid treatment. The model for end-stage liver disease may be a useful instrument for identifying patients prone to this outcome.

Preoperative evaluation of patients with liver disease

Patients with end-stage liver disease often undergo surgery for indications other than liver transplantation. These patients have an increased risk of morbidity and mortality that is related to their underlying liver disease. Assessments of surgical risk provide a basis for discussion of risks and benefits, treatment decision making, and for optimal management of patients for whom surgery is planned. The most useful indicators of surgical risk are indices that predict advanced disease, such as the Child-Turcotte-Pugh score, or those that predict prognosis, such as the Model for End-stage Liver Disease score. Careful preoperative risk assessment, patient selection, and management of various manifestations of advanced disease might decrease morbidity and mortality from nontransplant surgery in patients with liver disease.

Best practice in primary care pathology: review 5

This fifth best practice review examines three series of common primary care questions in laboratory medicine: (1) minor liver function test abnormalities; (2) laboratory monitoring of patients receiving lithium; and (3) investigation of possible venous thromboembolism. The review is presented in question-answer format, referenced for each question series. The recommendations represent a precis of guidance found using a standardised literature search of national and international guidance notes, consensus statements, health policy documents and evidence-based medicine reviews, supplemented by Medline Embase searches to identify relevant primary research documents. They are not standards but form a guide to be set in the clinical context. Most are consensus-based rather than evidence-based. They will be updated periodically to take account of new information.

Re-evaluation of serum alanine aminotransferase upper normal limit and its modulating factors in a large-scale population study

BACKGROUND

The upper normal limit (ULN) of serum alanine-aminotrasferase (ALT) normal range was recently challenged, because patients diagnosed with liver diseases may have 'normal' or near-'normal' ALT levels, and because possible modulators are often ignored in determining normal range.

AIM

To estimate the ULN for serum ALT and to identify factors modulating it.

SUBJECTS AND METHODS

We reviewed medical records of subjects aged 15-90, who underwent standard panels of laboratory tests, including serum ALT, over 6 months at a central laboratory. Three groups were defined: Group 1, comprised total study population (N=272 273). Group 2 (N=87 020) comprised total study population, excluding those receiving potentially hepatotoxic drugs, or diagnosed with liver disease, or had any abnormal laboratory test results other than for triglycerides, cholesterol, glucose, or HbA1c. Group 3 (N=17 496) the 'healthy' population, from whose ALT values we established the new ULN, comprised Group 2 subjects with normal triglycerides, cholesterol, glucose, and HbA1c levels.

RESULTS

The 95th percentile ALT values, corresponding to the ULN, in groups 1, 2, and 3 were 50.1, 40, and 37.5 U/l, respectively. 6.2% (16 943/273 273) of subjects whose ALT was below ULN listed by the test manufacturer (52 U/l), had ALT level above our new ULN. Linear and logistic-regression analyses showed that ALT levels were significantly modified by gender, age, glucose, cholesterol, triglycerides, and overweight/obesity diagnosis. Significant interaction was found between gender, glucose and cholesterol levels.

CONCLUSIONS

In this first large-scale study of 'healthy' population, serum ALT ULN was far lower than currently accepted value. Age and gender may be considered when determining the ULN for ALT.

Liver architecture maintenance by tincture of Crataegus against isoproterenol-induced myocardially infarcted rats

Myocardial infarction produces significant abnormal liver functioning. In the present study the hepatoprotective effect of tincture of Crataegus (TCR) in myocardially infarcted rats was investigated. The oral administration of TCR to rats for 30 days afforded good protection against isoproterenol-induced alterations in tissue marker enzymes of liver injury like alanine aminotransferase, aspartate aminotransferease, lactate dehydrogenase, and alkaline phosphatase and in protein-bound carbohydrates like hexose, hexosamine, fucose, and sialic acid. The protective effect of TCR was further supported by the reversal of isoproterenol-induced histological changes in the liver. The results suggest that TCR, which can protect the heart and circulatory system, can also be hepatoprotective and thereby maintain the near normal architecture of liver tissue.

Preoperative assessment of the patient with liver disease

Patients with liver disease are at appreciable risk when undergoing anesthesia and surgery. Attempts to quantify this risk have been thwarted by the diversity of disease states and illness severity that such patients bring to the operating theater and the myriad of procedures they may undergo. This review discusses the indications and contraindications for surgery in patients with liver disease and attempts to give specific recommendations for optimizing the clinical status of a patient with hepatic dysfunction prior to operative intervention.

Hepatic gene expression in patients with obesity-related non-alcoholic steatohepatitis

BACKGROUND

Non-alcoholic fatty liver disease (NAFLD) is among the most common causes of chronic liver disease. NAFLD includes a spectrum of clinicopathologic syndromes that includes non-alcoholic steatohepatitis (NASH) that has potential for progression. The pathogenesis of NASH is poorly characterized.

AIM

This study was designed to identify differences in hepatic gene expression in patients with NASH and to relate such differences to their clinical characteristics.

DESIGN

Consecutive patients undergoing bariatric surgery were prospectively recruited. Extensive clinical data and two liver biopsy specimens were obtained at the time of enrollment. A single hepatopathologist reviewed and classified the liver biopsies. Patients with excessive alcohol use and other causes of liver disease were excluded. A group of 29 NASH patients, 12 with steatosis alone, seven obese controls and six non-obese controls were selected for further investigation. Customized cDNA microarrays containing 5220 relevant genes were designed specifically for this study. Microarray experiments were run in triplicate for each sample and a selected group of genes were confirmed using real-time PCR.

OUTCOME MEASURE

Differential hepatic gene expressions in patients with NASH as compared with controls.

RESULTS

Thirty-four genes with significant differential expression were identified in patients with NASH when compared with non-obese controls. Moreover, 19 of these genes showed no significant expression differences in obese vs. non-obese controls, suggesting a stronger association of these genes to NASH.

CONCLUSIONS

Several differentially expressed genes in patients with NASH are related to lipid metabolism and extracellular matrix remodeling. Additionally, genes related to liver regeneration, apoptosis, and the detoxification process were differentially expressed. These findings may help clarify the molecular pathogenesis of NASH and identify potential targets for therapeutic intervention.

Palpable epigastric liver as a physical sign of cirrhosis: a prospective study

OBJECTIVE

Large numbers of patients present with abnormal liver function tests, but only a minority have significant liver disease. Physical examination may help in identifying patients with significant liver disease and in selecting patients who may require liver biopsy. Over a number of years we noted that a palpable liver in the epigastrium was common in patients with cirrhosis. The aim of this study was to evaluate this clinical sign in a cohort of patients undergoing liver biopsy.

METHODS

We prospectively studied 138 consecutive patients undergoing liver biopsy in a university teaching hospital. The main outcome measure was liver fibrosis measured using the standard METAVIR scoring system.

RESULTS

Thirty-eight patients had no fibrosis on biopsy, 11 patients had grade 1, eight patients had grade 2, 14 patients had grade 3 and 42 patients had grade 4 (cirrhosis). Palpable epigastric liver had a sensitivity of 86% and a specificity of 67% for the diagnosis of cirrhosis in this cohort.

CONCLUSION

We suggest that a palpable liver in the epigastrium is a useful physical sign of cirrhosis in clinical practice.

Controversies in liver biopsy: who, where, when, how, why?

Liver biopsy continues to have a central role in the evaluation of patients with suspected liver disease. The procedure is often indicated to evaluate otherwise unexplained liver biochemical test abnormalities, but the precise degree of serum aminotransferase elevations that should prompt a liver biopsy is controversial, as is the need for liver biopsy in all patients with suspected nonalcoholic fatty liver disease and chronic hepatitis C. Standard liver biopsy is contraindicated in patients with severe coagulopathy and ascites, although the degree of coagulopathy that contraindicates a liver biopsy is controversial. A transjugular approach is an alternative in patients with coagulopathy or ascites. Controversy surrounds all the technical aspects of liver biopsy, particularly the choice of needle (cutting vs suction) and the use of ultrasound to mark or guide the biopsy site. Bleeding is the major complication of liver biopsy, with a risk of 0.3%; cutting needles are more likely to cause hemorrhage than are suction needles. Traditionally, liver biopsy has been the province of the hepatologist/ gastroenterologist. However, an increasing number of liver biopsies are performed by radiologists. The implications of this trend with respect to patient outcome, safety, and training of fellows is unclear.

Non-alcoholic fatty liver syndrome: a hepatic consequence of common metabolic diseases

BACKGROUND AND AIMS

The association of liver steatosis with a number of common metabolic conditions has been suggested. The aim of the present study was to evaluate the clinical features of subjects with different severities of steatosis.

METHODS

The present study was performed in 282 consecutive patients with 'bright liver' at ultrasonography and in 58 subjects without steatosis. They had no history of alcohol abuse and negative tests for the presence of hepatitis B and C virus. Patients underwent clinical examination, anthropometry, laboratory tests and routine liver ultrasonography. Steatosis was graded as absent, mild, moderate and severe.

RESULTS

A progressive increase in the prevalence of obesity (P < 0.001), type 2 diabetes (P < 0.001), alanine aminotransferase (ALT) elevation (P < 0.001) and hypertriglyceridemia (P < 0.001), and a decrease of hypercholesterolemia (P < 0.05) was observed from the control group to the groups with mild, moderate and severe steatosis. More than half the subjects with liver steatosis had insulin resistance metabolic syndrome. Obesity, diabetes and hypertriglyceridemia were more common by 5.3-fold, 4.0-fold, and 6.7-fold, respectively, in subjects with severe steatosis, as compared to controls. Prevalence of obesity, diabetes and hyperlipidemia was significantly higher in subjects with fatty liver and ALT elevation.

CONCLUSION

Fatty liver can be considered as the hepatic consequence of common metabolic diseases.

Review article: Non-alcoholic fatty liver disease

Non-alcoholic fatty liver disease is a clinicopathological condition that comprises a wide spectrum of liver damage, ranging from simple steatosis to steatohepatitis, advanced fibrosis and cirrhosis. Non-alcoholic steatohepatitis represents only a stage within the spectrum of non-alcoholic fatty liver disease and is defined pathologically by the presence of steatosis together with necro-inflammatory activity. The true prevalence of non-alcoholic fatty liver disease is unknown, but it is estimated that it affects 10-24% of the general population in different countries. The diagnosis of non-alcoholic fatty liver disease is based upon convincing evidence of absent or minimal alcohol consumption, compatible histological changes in liver biopsy and the exclusion of other liver diseases. The natural history of non-alcoholic fatty liver disease remains to be defined. Patients with pure steatosis on liver biopsy follow a relatively benign course, whereas patients with histological necro-inflammatory changes and/or fibrosis may progress to end-stage liver disease. An initial step in the treatment of non-alcoholic fatty liver disease is the management of associated conditions, such as obesity, diabetes mellitus and hyperlipidaemia. Non-alcoholic fatty liver disease patients with steatohepatitis and/or fibrosis on liver biopsy may benefit from investigational pharmacological therapy. Patients with decompensated cirrhosis from non-alcoholic fatty liver disease may be candidates for liver transplantation.

Surgery in the patient with liver disease

Management of the surgical patient with liver disease begins with a careful preoperative assessment (Fig. 1). Any clues to liver disease on history and physical examination should be investigated to ascertain the cause of the clinical finding. More data on surgical patients with unexpected liver disease are now available. Patients undergoing emergent surgery are at significant risk of developing liver dysfunction. Child's class still correlates strongly to postoperative complications. Cornerstones of perioperative management in these patients are medical treatment of complications of chronic liver disease, such as ascites; coagulopathy; prevention of encephalopathy; and rapid treatment of dangerous postoperative complications, such as acute acalculous cholecystitis. Evolving knowledge of the effects of anesthesia, improving surgical techniques, and use of better diagnostic tests will help in the reduction of perioperative complications in these patients.

Severe autoimmune hepatitis in patients with previous spontaneous recovery of a flare

BACKGROUND/AIMS

Autoimmune hepatitis can present acutely and pursues a variable, usually progressive course. Spontaneous remissions have been described, but their influence on the course of subsequent attacks has not yet been studied.

METHODS

Charts from 1980 to 2000 were reviewed. Cases of autoimmune hepatitis were further examined to identify those with prior episodes of transient elevation of the serum aminotransferase activities of unknown etiology.

RESULTS

Fifty-one patients with autoimmune hepatitis were identified, nine of whom (18%) had experienced a transient episode of elevated aminotransferase activities which had resolved spontaneously. The median period of time separating the two flares was 10 months (range: 4 months-23 years). The median age at diagnosis was 41 years in both groups. More than 75% of the patients in either group suffered from a type 1 autoimmune hepatitis. Importantly, patients with spontaneous recovery of a previous episode had a higher serum alanine transaminase activity (P<0.02), were less likely to respond to immunosuppressive therapy (78 versus 98%, P=0.077) and required transplantation more frequently (22 versus 0%, P=0.028). Histologically, these patients did not have more fibrosis than patients without previous flare.

CONCLUSIONS

More than 10% of autoimmune hepatitis may begin with a spontaneously resolving episode. However, the spontaneous recovery of a previous attack should not falsely reassure: a subsequent flare of autoimmune hepatitis can still be severe.

Non-alcoholic fatty liver disease: an overview

Non-alcoholic fatty liver disease (NAFL) includes a spectrum of clinicopathological conditions with increasing prevalence in the developed world. Although steatosis alone seems to have a benign course, those patients with the diagnosis of non-alcoholic steatohepatitis (NASH) can have a progressive course. Additionally, there is now evolving, indirect evidence that some of the patients with cryptogenic cirrhosis may be the result of 'burned-out' NASH. Although NAFL and NASH are associated with insulin-resistance syndrome, some patients with NAFL may have no obvious risk factors. Despite preliminary data from a number of pilot studies, no established therapies can be offered to patients with NASH. Over the next few years, a number of exciting research projects dealing with the epidemiology as well as the pathogenesis of NAFL are expected to be completed. It is anticipated that, through a better understanding of NAFL, more effective treatment protocols can be developed targeting only those patients with NASH that are at the highest risk for progression to cirrhosis and liver failure.

Inducible nitric oxide synthase expression in chronic viral hepatitis and its relation with histological severity of disease

The role of nitric oxide in the pathogenesis of chronic viral hepatitis is not known. Elevated nitric oxide production is assumed to be responsible for the pathological changes in many inflammatory conditions, mainly via peroxynitrite, a potential oxidant that is produced by the reduction of superoxide anion with nitric oxide. The intensity and the distribution of the immunohistochemical staining of intrahepatic inducible nitric oxide synthase were studied in the biopsy specimens obtained from 63 patients with viral hepatitis and 13 patients with elevated transaminase levels of various aetiologies. Hepatic inducible nitric oxide synthase staining was significantly more intense in the viral hepatitis group (P = 0.000). Inducible nitric oxide synthase staining levels correlated well with the severity of the viral hepatitis using the Knodell's liver histological activity index (r = 0.393, P = 0.002) Among the viral hepatitis group, the pathological distribution of the inducible nitric oxide synthase staining favoured the periportal hepatocytes (zone 1) whereas less staining was observed in parenchymal hepatocytes zone of 2 and 3 and bile duct epithelium. As nitric oxide mediated nitration of hepatocellular proteins is elevated in inflamed hepatic tissues and is correlated with the severity of the disease, we suggest that inducible nitric oxide synthase can possibly have a critical role in the pathogenesis of chronic viral hepatitis.

Distinct enzyme profiles in patients with cryptogenic cirrhosis reflect heterogeneous causes with different outcomes after liver transplantation (OLT): a long-term documentation before and after OLT

BACKGROUND

Sound information is lacking about the clinical presentation of cryptogenic cirrhosis and its outcome after orthotopic liver transplantation (OLT).

METHODS

Among 856 patients who have been transplanted at our center, 40 patients had no evidence of any known etiologies and were therefore defined as suffering from cryptogenic cirrhosis. Their median follow-up period before OLT was 78 months (range, 1-264), and after OLT 97 months (range, 1-132). Laboratory and histological data were evaluated according to features being compatible either with a toxic, hepatitic, or cholestatic condition.

RESULTS

The clinical and histological findings differed specifically between these three groups. The toxic-like group (GGT 4-18 x upper limit of normal [ULN]) expressed significantly higher IgA levels, had histologically more often fatty liver changes, and risk factors for non-alcoholic steatohepatitis predominated (56% compared with 3% in the other groups, P=0.01). The hepatitic-like group (ALT 2-18 x ULN) showed histologically features of chronic hepatitis or hepatitic cirrhosis, and only among these patients a median International Autoimmune Hepatitis (IAH) score of 13 was found suggesting autoimmune hepatitis (AiH). In the cholestatic group (AP 2-8 x ULN) histology was compatible with a non-toxic inflammatory process but IAH score excluded AiH in all. After OLT, actuarial graft and patients survival was 90% at 5 years. Mild or moderate graft hepatitis occurred in 9 patients (23%) and was significantly associated with a pre-OLT IAH score >or= 10 (P =0.008).

CONCLUSIONS

This study provides arguments that cryptogenic cirrhosis is a heterogeneous disease in which autoimmune mechanisms might be predominately involved and being responsible for recurrence of chronic liver disease observed in some instances after OLT.

Autoimmune hepatitis: diagnostic criteria, subclassifications, and clinical features

The diagnosis of AIH depends on the finding of several suggestive features together with careful exclusion of liver diseases of other etiologies. Wherever possible, the diagnosis should be confirmed histologically by an experienced hepatopathologist. Seronegativity for the conventional autoantibodies at presentation does not exclude a diagnosis of AIH. It is important to test for anti-LKM1 antibodies to avoid missing a diagnosis of type 2 AIH, with potentially serious consequences. Although the syndrome is associated with characteristic biochemical abnormalities, and biochemical parameters are commonly used for monitoring response to therapy, it should be borne in mind that neither these nor autoantibody titers are completely reliable indices of disease activity. Although the various systems that have been promulgated for classification of the disease may identify different groups of patients on pathogenetic or clinical criteria and are useful for research purposes, none is yet sufficiently exclusive in terms of defining prognosis or planning treatment strategies to be applicable to the individual patient seen in the clinic. Clinical management should therefore continue to be individually tailored.

Prevalence and epidemiology of autoimmune hepatitis

The incidence and characteristics of AIH differ in various geographic regions. Based on limited epidemiologic studies, the incidence of type 1 AIH among Caucasoid populations of Europe and North America ranges from 0.1 to 1.9/100,000/year. The disease is considerably less frequent in Japan. The relative proportion of AIH among cases with chronic hepatitis is low in regions with a high prevalence of viral hepatitis. Type 2 AIH is more frequent in southern Europe than in northern Europe, the United States, and Japan. The occurrence of anti-SLA/LP is also higher in European than in Japanese patients with type 1 AIH. The frequency of HLA markers that affect susceptibility to AIH varies between ethnic groups. DRB1*0301 (DR3) and DRB1*0401 (DR4) are the major risk factors for type 1 AIH in white European and North American populations. DRB1*0405 (DR4) is the principal risk factor in Japanese and adult Argentine patients with type 1 AIH, and DRB1*0404 (DR4) is the main susceptibility allele in Mestizo Mexicans. Children may have different clinical manifestations than adults, and the diagnoses of type 2 AIH, autoimmune sclerosing cholangitis, and APS1 should be considered. Uniform application of diagnostic criteria formulated by the International Autoimmune Hepatitis Group should strengthen future epidemiologic studies and extend awareness of AIH to yet unstudied minority groups.

Non-alcoholic fatty liver disease

Non-alcoholic fatty liver disease (NAFLD) is a chronic liver disease that affects a high proportion of the world's population. Insulin resistance and oxidative stress play a critical role in the pathogenesis of NAFLD. Clinical, biochemical and imaging studies are of value in the diagnostic evaluation of patients with NAFLD, but liver biopsy remains the most sensitive and specific means of providing important diagnostic and prognostic information. Simple steatosis has the best prognosis within the spectrum of NAFLD, but NAFLD has the potential to progress to steatohepatitis, fibrosis and even cirrhosis. No effective medical therapy is currently available for all patients with NAFLD. In patients with diabetes mellitus and hyperlipidemia, appropriate metabolic control is always recommended, but rarely effective in resolving the liver disease. Weight reduction, when achieved and sustained, may improve the liver disease, although the results with weight loss have been inconsistent. Pharmacological therapy aimed at the underlying liver disease holds promise. Several medications with different mechanisms of action and potential benefit are currently being evaluated in clinical trials. Liver transplantation is a life-extending therapeutic alternative for patients with end-stage NAFLD, but NAFLD may recur after liver transplantation.

[The importance of AST / ALT rate in nonalcoholic steatohepatitis diagnosis]

BACKGROUND/AIMS

There is a histologic similarity between nonalcoholic steatohepatitis and alcoholic liver disease and in some cases differential diagnosis may be difficult, since some patients do not report abusive alcohol consumption.

OBJECTIVE

Evaluating the usefulness of setting the rate AST/ALT for the differential diagnosis of nonalcoholic steatohepatitis and alcoholic liver disease.

PATIENTS AND METHODS

Twenty nine obese patients with nonalcoholic steatohepatitis were compared with 28 patients with alcoholic liver disease. The diagnosis of nonalcoholic steatohepatitis was made after exclusion of other causes of liver disease and by histologic findings of, at least, macrovesicular steatosis and hepatocellular necrosis.

RESULTS

In patients with nonalcoholic steatohepatitis the medium AST value was 52.3 +/- 21.2 U/L and ALT of 90.1 +/- 37.9 U/L, being the AST/ALT rate lower than 1 in all patients. In patients with alcoholic liver disease the medium AST value was 140 +/- 82.5 U/L and ALT was 50.6 +/- 40.3 U/L. The rate was higher than 1 in all cases and higher than 2 in 24 (85.7%), being statistically significant when compared with patients with nonalcoholic steatohepatitis.

CONCLUSION

The AST/ALT rate seems to be useful in the differential diagnosis of liver diseases, while lower than 1 is highly suggestive of nonalcoholic steatohepatitis.

A systematic review of the diagnostic accuracy of physical examination for the detection of cirrhosis

BACKGROUND

We conducted a review of the diagnostic accuracy of clinical examination for the diagnosis of cirrhosis. The objectives were: to identify studies assessing the accuracy of clinical examination in the detection of cirrhosis; to summarize the diagnostic accuracy of reported physical examination findings; and to define the effects of study characteristics on estimates of diagnostic accuracy.

METHODS

Studies were identified through electronic literature search of MEDLINE (1966 to 2000), search of bibliographic references, and contact with authors. Studies that evaluated indicants from physical examination of patients with known or suspected liver disease undergoing liver biopsy were included. Qualitative data on study characteristics were extracted. Two-by-two tables of presence or absence of physical findings for patients with and without cirrhosis were created from study data. Data for physical findings reported in each study were combined using Summary Receiver Operating Characteristic (SROC) curves or random effects modeling, as appropriate.

RESULTS

Twelve studies met inclusion criteria, including a total of 1895 patients, ranging in age from 3 to 90 years. Most studies were conducted in referral populations with elevated aminotransferase levels. Ten physical signs were reported in three or more studies and ten signs in only a single study. Signs for which there was more study data were associated with high specificity (range 75-98%), but low sensitivity (range 15-68%) for histologically-proven cirrhosis.

CONCLUSIONS

Physical findings are generally of low sensitivity for the diagnosis of cirrhosis, and signs with higher specificity represent decompensated disease. Most studies have been undertaken in highly selected populations.

Findings on liver biopsy to investigate abnormal liver function tests in the absence of diagnostic serology

BACKGROUND/AIMS

The significance of abnormal liver function tests in the absence of diagnostic serology is unclear. The aim of this study was to report liver biopsy findings in a large group of patients with unexplained abnormal liver biochemistry.

METHODS

Histological findings were examined in 354 patients who underwent liver biopsy to investigate abnormal liver function tests.

RESULTS

Six percent of patients had a normal liver biopsy while 26% were found to have some degree of fibrosis and 6% were cirrhotic. Thirty four and 32% of biopsies suggested non-alcoholic steatohepatits or fatty liver respectively. Other diagnoses included cryptogenic hepatitis, drug toxicity, primary and secondary biliary cirrhosis, autoimmune hepatits, alcohol-related liver disease, primary sclerosing cholangitis, haemochromatosis, amyloid and glycogen storage disease. Patient management was directly altered in 18% of patients due to liver biopsy findings and three families were entered into screening programmes for inheritable liver disease.

CONCLUSIONS

The finding of abnormal liver function tests in the absence of diagnostic serology may indicate significant liver disease. Liver biopsy yields a range of liver diseases of diverse nature and extent. Liver diseases may be uncovered for which specific treatment is indicated.

Diagnosis and monitoring of hepatic injury. II. Recommendations for use of laboratory tests in screening, diagnosis, and monitoring

Purpose: To review information on the use of laboratory tests in screening, diagnosis, and monitoring of acute and chronic hepatic injury.

Data Sources and Study Selection: A MEDLINE search was performed for key words related to hepatic diseases, including acute hepatitis, chronic hepatitis, alcoholic hepatitis, cirrhosis, hepatocellular carcinoma, and etiologic causes. Abstracts were reviewed, and articles discussing use of laboratory tests selected for review. Additional articles were selected from the references.

Guideline Preparation and Review: Drafts of the guidelines were posted on the Internet, presented at the AACC Annual Meeting in 1999, and reviewed by experts. Areas requiring further amplification or literature review were identified for further analysis. Specific recommendations were made based on analysis of published data and evaluated for strength of evidence and clinical impact.

Recommendations: Although many specific recommendations are made in the guidelines, only some summary recommendations are listed here. In acute hepatic injury, prothrombin time and, to a lesser extent, total bilirubin are the best indicators of severity of disease. Although ALT is useful for detecting acute and chronic hepatic injury, it is not related to severity of acute hepatic injury and only weakly related to severity of chronic hepatic injury. Specific tests of viral markers should be the initial differential tests in both acute and chronic hepatic injury; when positive, they are also useful for monitoring recovery from hepatitis B and C.

An assessment of the role of liver biopsies in asymptomatic patients with chronic liver test abnormalities

OBJECTIVE

The role of liver biopsy in the management of patients with nonspecific chronic liver enzyme abnormalities is not well established. The aim of this study is to determine whether liver histology changes the clinical impression formed before liver biopsy and the preliminary management plan.

METHODS

Consenting asymptomatic adult patients with persistent (> or = 6 months) liver test abnormalities were enrolled. Patients with a strong suspicion for a specific liver disease were excluded. A presumptive diagnosis and a preliminary management plan were documented before a liver biopsy. After the liver biopsy, the patients were reassessed to determine the effect of the biopsy on the diagnosis and management plan.

RESULTS

A total of 36 patients were enrolled: 15 men and 21 women, with a median age of 51 yr. The prebiopsy diagnoses were nonalcoholic steatohepatitis (24), autoimmune hepatitis (3), primary biliary cirrhosis (2), primary sclerosing cholangitis (2), and miscellaneous (5 patients). The liver biopsy changed the diagnosis in 14% of cases. Lifestyle recommendations were not significantly altered by the biopsy. The liver biopsy affected the frequency of liver test monitoring in 13 patients (36%). Treatment recommendations were affected in 12 cases, 10 of whom were offered investigational therapy.

CONCLUSIONS

Although a liver biopsy may help to definitively establish the final diagnosis in patients, the results alter the presumptive prebiopsy diagnosis infrequently, and no proven therapy exists for the vast majority of these patients. Therefore, the risks and benefits of a liver biopsy should be carefully weighed, especially in settings in which investigational therapies are unavailable.

Prevalence of obesity and diabetes in patients with cryptogenic cirrhosis: a case-control study

It has recently been suggested that nonalcoholic steatohepatitis (NASH) is an under-recognized cause of cryptogenic cirrhosis (CC) on the basis of higher prevalence of obesity and type II diabetes among these patients. To test this hypothesis, we studied 65 consecutive patients with advanced cirrhosis (Child-Pugh Score >/= 7) of undetermined etiology (CC) from our active waiting list for liver transplantation in January 1993, 1996, and 1999. For each patient, we selected 2 age- and sex-matched controls from the corresponding lists. The prevalence of obesity (defined as body mass index [BMI] >/= 30) and diabetes were compared between the groups. Sixteen patients (and their 32 controls) with CC were excluded as further review of records suggested other possible etiologies. Thus, the final analysis included 49 patients and 98 controls. The etiology of cirrhosis in the control group was alcohol in 16.3%, chronic viral hepatitis in 30.6%, autoimmune hepatitis in 8.2%, and primary biliary cirrhosis (PBC) or primary sclerosing cholangitis in 35.7%. The prevalence of obesity (55% vs. 24%) and type II diabetes (47% vs. 22%) was significantly higher in patients with CC compared with controls. Twenty-three percent of patients with CC had both obesity and diabetes compared with 5% among controls (P =.002). There was no difference in the prevalence of hypercholesterolemia (serum cholesterol > 200 mg/dL) between the groups. In conclusion, patients with advanced CC are more likely to be obese and diabetic compared with age- and sex-matched patients with advanced cirrhosis. This supports the hypothesis that NASH may be an etiological factor in some of the patients with CC.

Serum triglycerides, the liver and the pancreas

Massive hypertriglyceridaemia associated with fatty liver and abdominal pain or frank pancreatitis (the chylomicronaemia syndrome) is uncommon, but clinically important and under-recognized. It may arise as a result of severe genetic defects in lipolysis or, more commonly, from a moderate primary hypertriglyceridaemia that is exacerbated by a secondary cause. The latter include several drugs, among which the protease inhibitors, used for the treatment of human immunodeficiency virus infection, are increasingly apparent. In the acute situation plasma exchange, fat-free parenteral nutrition and acute insulin treatment, even in nondiabetic persons, may be valuable. A potentially major advance in prophylaxis is the use of high-dose antioxidant therapy, which has been shown to reduce attacks of pancreatitis even in the absence of a reduction in serum triglycerides. Asymptomatic patients with abnormal liver function tests are common in the lipid clinic, and can be a difficult group in which to make management decisions. Among those who are not taking excessive amounts of alcohol, many will have nonalcoholic steatohepatitis. The care of these patients is discussed, but there remains considerable uncertainty regarding their optimum management and prognosis.

Abnormal findings on liver function tests. Interpreting results to narrow the diagnosis and establish a prognosis

Evaluating abnormal liver test results requires careful attention to the corresponding clinical data obtained during history taking and physical examination. Generally, it is helpful to separate liver tests into three categories: tests that assess synthetic function, tests that assess hepatocellular necrosis (hepatocellular enzymes), and tests that assess cholestasis. The clinical setting together with the specific pattern of liver function abnormalities can narrow differential diagnosis and provide a cost-effective approach to assessing patients and identifying those who need liver biopsy.