ACG临床指南：异常肝脏化学评价

StephenW

Am J Gastroenterol 2017; 112:18–35; doi:10.1038/ajg.2016.517; published online 20 December 2016
ACG Clinical Guideline: Evaluation of Abnormal Liver Chemistries

Paul Y Kwo MD, FACG, FAASLD1, Stanley M Cohen MD, FACG, FAASLD2 and Joseph K Lim MD, FACG, FAASLD3

    1Division of Gastroenterology/Hepatology, Department of Medicine, Stanford University School of Medicine, Palo Alto, California, USA
    2Digestive Health Institute, University Hospitals Cleveland Medical Center and Division of Gastroenterology and Liver Disease, Department of Medicine, Case Western Reserve University School of Medicine, Cleveland, Ohio, USA
    3Yale Viral Hepatitis Program, Yale University School of Medicine, New Haven, Connecticut, USA

Correspondence: Paul Y. Kwo, MD, FACG, FAASLD, Division of Gastroenterology/Hepatology, Stanford University School of Medicine, 750 Welch Road, Suite 210, Palo Alto, California 94304, USA. E-mail: [email protected]

Received 1 February 2016; Accepted 1 September 2016
Advance online publication 20 December 2016

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Abstract

Clinicians are required to assess abnormal liver chemistries on a daily basis. The most common liver chemistries ordered are serum alanine aminotransferase (ALT), aspartate aminotransferase (AST), alkaline phosphatase and bilirubin. These tests should be termed liver chemistries or liver tests. Hepatocellular injury is defined as disproportionate elevation of AST and ALT levels compared with alkaline phosphatase levels. Cholestatic injury is defined as disproportionate elevation of alkaline phosphatase level as compared with AST and ALT levels. The majority of bilirubin circulates as unconjugated bilirubin and an elevated conjugated bilirubin implies hepatocellular disease or cholestasis. Multiple studies have demonstrated that the presence of an elevated ALT has been associated with increased liver-related mortality. A true healthy normal ALT level ranges from 29 to 33 IU/l for males, 19 to 25 IU/l for females and levels above this should be assessed. The degree of elevation of ALT and or AST in the clinical setting helps guide the evaluation. The evaluation of hepatocellular injury includes testing for viral hepatitis A, B, and C, assessment for nonalcoholic fatty liver disease and alcoholic liver disease, screening for hereditary hemochromatosis, autoimmune hepatitis, Wilson’s disease, and alpha-1 antitrypsin deficiency. In addition, a history of prescribed and over-the-counter medicines should be sought. For the evaluation of an alkaline phosphatase elevation determined to be of hepatic origin, testing for primary biliary cholangitis and primary sclerosing cholangitis should be undertaken. Total bilirubin elevation can occur in either cholestatic or hepatocellular diseases. Elevated total serum bilirubin levels should be fractionated to direct and indirect bilirubin fractions and an elevated serum conjugated bilirubin implies hepatocellular disease or biliary obstruction in most settings. A liver biopsy may be considered when serologic testing and imaging fails to elucidate a diagnosis, to stage a condition, or when multiple diagnoses are possible.

StephenW

Am J Gastroenterol 2017; 112：18-35; doi：10.1038 / ajg.2016.517; 2016年12月20日在线发布
ACG临床指南：异常肝脏化学评价

Paul Y Kwo MD，FACG，FAASLD1，Stanley M Cohen MD，FACG，FAASLD2和Joseph K Lim MD，FACG，FAASLD3

    胃肠病学/肝病学，医学部，斯坦福大学医学院，帕洛阿尔托，美国加利福尼亚州
    2维健康研究所，大学医院Cleveland医学中心和胃肠病学和肝病科，西医储备大学医学院，克利夫兰，俄亥俄州，美国医学部
    3耶鲁大学医学院，纽黑文，康涅狄格州，美国的病毒性肝炎计划

通讯：Paul Y.Kwo，MD，FACG，FAASLD，Division of Gastroenterology / Hepatology，Stanford University School of Medicine，750Welch Road，Suite 210，Palo Alto，California 94304，USA。电子邮件：[email protected]

收到2016年2月1日;接受2016年9月1日
提前在线公布2016年12月20日

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临床医生需要每天评估异常肝化学。最常见的肝化学是血清丙氨酸氨基转移酶（ALT），天冬氨酸转氨酶（AST），碱性磷酸酶和胆红素。这些测试应被称为肝化学或肝脏测试。肝细胞损伤定义为与碱性磷酸酶水平相比AST和ALT水平不成比例的升高。胆汁淤积性损伤定义为与AST和ALT水平相比碱性磷酸酶水平不成比例的升高。大多数胆红素作为非共轭胆红素循环，并且升高的结合胆红素意味着肝细胞疾病或胆汁淤积。多项研究表明，ALT升高与肝脏相关死亡率增加有关。真正健康的正常ALT水平范围为男性为29至33IU / l，女性为19至25IU / l，并​​且应评估高于此水平的水平。临床设置中ALT和/或AST的升高程度有助于指导评估。肝细胞损伤的评价包括测试病毒性甲型肝炎，乙型肝炎和丙型肝炎，评估非酒精性脂肪肝病和酒精性肝病，筛选遗传性血色素沉着病，自身免疫性肝炎，威尔森氏病和α-1抗胰蛋白酶缺乏症。此外，应寻求处方和非处方药的历史。对于确定为肝源的碱性磷酸酶升高的评估，应进行原发性胆管胆管炎和原发性硬化性胆管炎的测试。总胆红素升高可发生在胆汁淤积性或肝细胞性疾病中。升高的总血清胆红素水平应分级为直接和间接胆红素级分，升高的血清结合胆红素意味着肝细胞疾病或胆道梗阻在大多数情况下。当血清学测试和成像未能阐明诊断，分期或可能进行多个诊断时，可以考虑肝活检。