LA CONSULTA SEMANAL

 

ABRIL 2000

 

 

CONSULTA

Evaluación de enzimas hepáticas elevadas en pacientes asintomáticos

 

N Engl J Med 2000 Apr 27;342(17):1266-1271 

Review Articles: Primary Care: Evaluation of Abnormal Liver-Enzyme Results in Asymptomatic Patients. 

Pratt DS, Kaplan MM 

From New England Medical Center, Box 217, 750 Washington St., Boston, MA 02111, where reprint requests should be addressed to Dr. Pratt. 

 

Postgrad Med 2000 Feb;107(2):100-2, 105-9, 113-4 [Texto completo]

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

Gopal DV, Rosen HR 

Division of Gastroenterology and Hepatology, Oregon Health Sciences University School of Medicine, Portland, USA. 

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. 

 

Am J Gastroenterol 1999 Oct;94(10):3010-4 

Prospective evaluation of unexplained chronic liver transaminase abnormalities in asymptomatic and symptomatic patients. 

Daniel S, Ben-Menachem T, Vasudevan G, Ma CK, Blumenkehl M 

Department of Pathology, Henry Ford Hospital, Detroit, Michigan, USA. 

OBJECTIVES: It is currently recommend to perform a liver biopsy for patients with chronically elevated liver function tests (LFT) of unknown etiology (marker negative). The necessity and benefits of these recommendations are unknown. The aims of this study were to determine the prevalence of marker-negative LFT in patients referred for evaluation of chronically elevated LFT; to determine the prevalence of diseases that may be associated with marker-negative abnormal LFT; and to assess whether a liver biopsy alters the management of such patients. METHODS: We conducted a prospective observational study of 1124 adults referred for evaluation of chronically elevated LFT.Patients who consented to a liver biopsy were eligible. Marker-negative abnormal LFT was defined as the absence of accepted serum markers for infectious, metabolic, autoimmune, or hereditary liver disease, the absence of a history of alcohol or hepatotoxic drug use, and the absence of signs of chronic liver disease. RESULTS: Eighty-one of 1124 eligible patients were marker-negative. Liver biopsies in the 81 marker-negative patients revealed: normal histology (eight), steatosis (41), steatohepatitis (26), fibrosis (four), and cirrhosis (two). All 73 abnormal liver biopsies had some degree of steatosis. There were no significant associations between histological findings and the presence of obesity (p = 0.13), hyperlipidemia (p = 0.4), or diabetes (p = 0.9). There were no significant associations when classifying patients by gender or by symptoms. CONCLUSION: In the setting of marker-negative elevated LFT, the most likely histological diagnosis is fatty metamorphosis of the liver with occasional associated fibrosis. 

 

Am Fam Physician 1999 Apr 15;59(8):2223-30 [Texto completo] 

Special considerations in interpreting liver function tests. 

Johnston DE 
Division of Gastroenterology, University of New Mexico School of Medicine, Albuquerque 87131-5271, USA. 

A number of pitfalls can be encountered in the interpretation of common blood liver function tests. These tests can be normal in patients with chronic hepatitis or cirrhosis. The normal range for aminotransferase levels is slightly higher in males, nonwhites and obese persons. Severe alcoholic hepatitis is sometimes confused with cholecystitis or cholangitis. Conversely, patients who present soon after passing common bile duct stones can be misdiagnosed with acute hepatitis because aminotransferase levels often rise immediately, but alkaline phosphatase and gamma-glutamyltransferase levels do not become elevated for several days. Asymptomatic patients with isolated, mild elevation of either the unconjugated bilirubin or the gamma-glutamyltransferase value usually do not have liver disease and generally do not require extensive evaluation. Overall hepatic function can be assessed by applying the values for albumin, bilirubin and prothrombin time in the modified Child-Turcotte grading system. 

 

Cleve Clin J Med 1998 Mar;65(3):150-8 

Evaluating asymptomatic patients with mildly elevated liver enzymes. 

Younossi ZM 

Department of Gastroenterology, Cleveland Clinic, USA. 

Because elevated liver enzymes are found in 1% to 4% of asymptomatic persons, extensive evaluation of all abnormal tests would expose many patients to undue risks and medical costs. On the other hand, not evaluating minor elevations of liver enzymes could result in missing the early diagnosis of potentially treatable disorders. This review discusses likely causes of elevated aminotransferase, alkaline phosphatase, and gamma-glutamyl transferase levels and provides algorithms for evaluating abnormal liver enzyme values in apparently healthy patients in the primary care setting. 

 

Harefuah 1998 Aug;135(3-4):89-92, 168 

[Abnormal liver function tests in the primary care setting]. 

[Article in Hebrew] 

Vinker S, Nakar S, Nir E, Hyam E, Weingarten MA 

Dept. of Family Medicine, Rabin Medical Center, Sackler Faculty of Medicine, Tel Aviv, Israel. 

Results of laboratory tests ordered during a primary care encounter may reveal findings of abnormal liver function tests, including elevated liver enzymes, hyperbilirubinemia, hypoalbuminemia or abnormal coagulation tests. The object of this study was to describe the spectrum of these liver function test (LFT) abnormalities in primary care. Results of all laboratory tests ordered during 10 months in an urban primary care clinic were retrospectively reviewed and the medical charts of patients with abnormal LFTs were studied. In 217/1088 (20%) of the tests at least 1 LFT abnormality was found in 156 patients. New diagnoses were made in 104 patients. The main diagnostic groups were: non-alcoholic fatty liver changes, Gilbert's disease, acute infectious hepatitis, alcoholic liver disease and cirrhosis and hepatotoxic drug injury. In 60 patients the physician classified the abnormality as negligible and not associated with significant disease. However, an abnormal test that had been ordered for evaluation of a specific complaint, was indeed likely to represent significant disease (X2 = 29.5, p < 0.001). We conclude that finding abnormalities in liver function tests is common in the primary care clinic but does not often indicate significant liver disease. 

 

Med Clin North Am 1996 Sep;80(5):887-906 

Evaluation of abnormal liver function tests. 

Moseley RH 

Gastroenterology Section, Ann Arbor Department of Veterans Affairs Medical Center, Michigan 48105, USA. 

Although the liver can be affected in a wide range of disorders, the differential diagnosis of abnormal liver function tests can be substantially narrowed by a comprehensive history and physical examination and by the recognition of relatively distinct biochemical patterns of liver injury. Although referral to a specialist may be required for the performance of, for example, percutaneous liver biopsy and long-term management of chronic liver disease, a presumptive diagnosis can usually be made in the vast majority of patients who present to primary care physicians with abnormal liver function tests. 

 

Am Fam Physician 1996 May 1;53(6):2111-9 

Evaluating asymptomatic patients with abnormal liver function test results. 

Theal RM, Scott K 

Department of Family Medicine, Kaiser Permanente Medical Center, Fontana, CA 92335-6720, USA.

Asymptomatic patients with abnormal results on liver function test pose a diagnostic challenge. In general, determinations of routinely ordered tests of liver function are neither sensitive nor specific for liver disease. Fatty liver, alcohol-related liver damage and chronic viral hepatitis are the most common causes of abnormal liver function test results in asymptomatic patients. Causes of asymptomatic liver disease include hemochromatosis, Wilson's disease, drug toxicity, chronic autoimmune hepatitis, biliary cirrhosis, sclerosing cholangitis, alpha1-antitrypsin deficiency and sarcoidosis. The most efficient screening tests for liver damage are alanine transaminase, alkaline phosphatase and bilirubin. Repeat testing when results are abnormal, and use of ancillary tests, such as creatine phosphokinase or gamma-glutamyl-transferase, may confirm liver damage. Imaging studies help exclude biliary obstruction or neoplasm. Treatable illnesses should be ruled out. Three to six months of observation for progressive symptoms and liver dysfunction may follow. After the period of observation, further laboratory tests, a diagnostic liver biopsy and/or referral to gastroenterologist may be needed.  

 

Mayo Clin Proc 1996 Nov;71(11):1089-94; quiz 1094-5 

Clinical approach to the patient with abnormal liver test results. 

Kamath PS 

Division of Gastroenterology and Internal Medicine, Mayo Clinic Rochester, MN 55905, USA. 

Abnormal results of standard biochemical liver tests occur frequently; however, the prevalence of clinically significant liver disease is only about 1% in all patients screened. Thus, development of a rational and cost-effective approach to these patients is important. Liver diseases are generally classified as hepatocellular, cholestatic, and infiltrative. Cholestatic liver disease is further categorized as intrahepatic and extrahepatic. Hepatocellular disease is characterized by transaminase increases greater than 5 times the upper limit of normal, with alkaline phosphatase levels usually increased less than 2 to 3 times the upper limit of normal. Cholestatic disease is characterized by an increase in the alkaline phosphatase level that is 3 to 5 times greater than the upper limit of normal, with only a mild increase of transaminases. The exception to this is cholestasis with cholangitis when the transaminases can be more substantially increased. In infiltrative diseases of the liver such as lymphoma or granulomatous hepatitis, the alkaline phosphatase level is increased disproportionately to that of the bilirubin. Specific etiologic diagnoses cannot usually be based on routine biochemical liver test results, and thus more specialized serum tests are necessary. A liver biopsy is often needed for a precise diagnosis in patients with long-term increases in liver test results. Ultrasonography is the best initial imaging technique for the liver, and if biliary dilatation is noted, endoscopic retrograde cholangiopancreatography is recommended. 

 

Postgrad Med 1993 Feb;93(2):119-20, 125, 129-32 

Abnormal liver enzyme levels. Clinical evaluation in asymptomatic patients. 

Herrera JL 

Division of Gastroenterology, University of South Alabama College of Medicine, Mobile 36617.

Chronic elevation of liver enzyme levels requires attention, because it may indicate serious liver disease. The pattern of elevation, whether hepatocellular or cholestatic, is used to guide the evaluation. The goal is to diagnose treatable forms of liver disease. Occasionally, a diagnosis cannot be established with noninvasive screening tests, and regular follow-up is then recommended. The role of liver biopsy in such cases is controversial.  

 

Postgrad Med 1991 Mar;89(4):137-41 

Abnormal liver enzyme levels. Evaluation in asymptomatic patients. 

King PD 

Department of Medicine, University of Missouri-Columbia School of Medicine 65212. 

Chronic elevation of serum aminotransferase levels, even in the absence of symptoms, often reflects chronic hepatitis or other significant underlying liver disease. Patients with persistently abnormal alkaline phosphatase levels may have extrahepatic biliary tract disease or a chronic cholestatic disorder. Physicians can discover unsuspected liver disease without undue risk, expense, or inconvenience to the patient by means of the following: a carefully taken history and thorough physical examination, appropriate timing of follow-up blood tests, and timely referral for percutaneous liver biopsy or endoscopic retrograde cholangiopancreatography. 

 

Am Fam Physician 1989 Mar;39(3):117-26 

Abnormal liver function tests in asymptomatic patients. 

McKenna JP, Moskovitz M, Cox JL 

Medical Center, Beaver, Pennsylvania. 

Liver function abnormalities are often found on routine chemical profiles. Abnormal test results are often false positive in asymptomatic patients. Repeat testing and confirmation that the liver is the source of the abnormality are the first steps of evaluation. A thorough history and physical examination may suggest reasons for the abnormalities. If no etiology for the abnormal test result is found, further testing is indicated.

 

 

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