hepatic and biliary disorders
Overview of Chronic Hepatitis
Diagnosis of Chronic Hepatitis
Liver test results compatible with hepatitis Viral serologic tests Possibly autoantibodies, immunoglobulins, alpha-1 antitrypsin level, and other tests Occasionally biopsy Serumalbumin, platelet count, and prothrombin time/international normalized ratio (PT/INR) (See also the practice guidelineHepatitis C Guidance 2019 Update: American Association for the Study of Liver Disease–Infectious Diseases Society of America Recommendations for Testing, Managing, and Treating Hepatitis C Virus Infectionand the U.S. Preventive Services Task Force’s clinical guidelineHepatitis C Virus Infection in Adolescents and Adults: Screening.) Chronic hepatitis is suspected in patients with any of the following: Suggestive symptoms and signs Incidentally noted elevations in aminotransferase levels Previously diagnosed acute hepatitis In addition, to identify asymptomatic patients, the Centers for Disease Control (CDC) recommends testing of all adults≥18 years at least once for hepatitis C. Liver tests are needed if not previously done and include serum alanine aminotransferase (ALT), aspartate aminotransferase (AST), alkaline phosphatase, and bilirubin. are the most characteristic laboratory abnormalities (ALT normal values: 29 to 33 IU/L [0.48 to 55 microkat/L] for males and 19 to 25 IU/L [0.32 to 0.42 microkat/L] for females [ Diagnosis reference ]). ALT is usually higher than AST. Aminotransferase levels can be normal during chronic hepatitis if the disease is quiescent, particularly with HCV infection and is usually normal or only slightly elevated but is occasionally markedly high, particularly in Primary Biliary Cholangitis (PBC) . Bilirubinis usually normal unless the disease is severe or advanced. If laboratory results are compatible with hepatitis, viral serologic tests are done to exclude HBV and HCV (see tables Hepatitis B Serology* and The next tests done include Autoantibodies (antinuclear antibody, anti–smooth muscle antibody, antimitochondrial antibody, liver-kidney microsomal antibody) Immunoglobulins Serum transferrin saturation and ferritin Laboratory Testing of Thyroid Function (thyroid-stimulating hormone) Diagnosis (tissue transglutaminase antibody) Alpha-1 antitrypsin level Ceruloplasmin Children and young adults are screened for Wilson disease by measuring the ceruloplasmin level. Autoimmune hepatitis is normally diagnosed based on the presence of antinuclear (ANA), anti–smooth muscle (ASMA), or anti-liver/kidney microsomal type 1 (anti-LKM1) antibodies at titers of 1:80 (in adults) or 1:20 (in children) and usually elevations in serum immunoglobulins. Antimitochondrial antibodies most often present in primary biliary cholangitis. (See also the American Association for the Study of Liver Disease's practice guidelineDiagnosis and Management of Autoimmune Hepatitis in Adults and Children: 2019 Practice Guidance and Guidelines From the American Association for the Study of Liver Diseases.) Serum transferrin saturation > 45% and elevated ferritin suggests hereditary hemochromatosis and should be followed by genetic testing for the hemochromatosis gene (HFE). , a low platelet count, or prolonged PT may suggest Cirrhosis and even If the cause of hepatitis is identified, noninvasive tests (eg, ultrasound elastography, serum markers) can be done to assess the degree of liver Hepatic Fibrosis . Unlike in acute hepatitis, biopsy may be necessary to confirm the diagnosis or etiology of chronic hepatitis. Mild cases may have only minor hepatocellular necrosis and inflammatory cell infiltration, usually in portal regions, with normal acinar architecture and little or no fibrosis. Such cases rarely develop into clinically important liver disease or cirrhosis. In more severe cases, biopsy typically shows periportal necrosis with mononuclear cell infiltrates (piecemeal necrosis) accompanied by variable periportal fibrosis and bile duct proliferation. The acinar architecture may be distorted by zones of collapse and fibrosis, and frank cirrhosis sometimes coexists with signs of ongoing hepatitis. Biopsy is also used to grade and stage the disease, although noninvasive testing (serum markers or elastrography) is now often used instead of liver biopsy to stage fibrosis. One of the simplest markers to stage fibrosis is the FIB4 index, which uses aspartate aminotransferase (AST), alanine aminotransferase (ALT), platelets, and age to assess risk of advanced fibrosis. Other modalities include transient elastography or MR elastography If symptoms or signs of Cryoglobulinemia develop during chronic hepatitis, particularly with HCV, cryoglobulin levels and rheumatoid factor should be measured; high levels of rheumatoid factor and low levels of complement suggest cryoglobulinemia. Patients with chronic HBV infection or cirrhosis due to any underlying liver disorder should be screened every 6 months for Hepatocellular Carcinoma with ultrasonography and sometimes serum alpha-fetoprotein measurement, although the cost-effectiveness of this practice, particularly alpha-fetoprotein measurement, is debated. (See also the Cochrane review abstract 1.Kwo PY, Cohen SM, Lim JK: ACG Clinical Guideline: Evaluation of Abnormal Liver Chemistries.Am J Gastroenterol112 (1):18-35, 2017. doi: 10.1038/ajg.2016.517. 