评估异常肝化学：临床指南

StephenW

Evaluating abnormal liver chemistries: a clinical guideline                   Share this content:        

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                The ACG has released recommendations of preferred approaches for diagnosing and evaluating patients with abnormal liver test results.        
    The American College of Gastroenterology (ACG) has released a clinical practice guideline regarding the evaluation of abnormal liver chemistries.
The investigators reviewed evidence from the MEDLINE and EMBASE databases regarding the evaluation of abnormal liver chemistries, studies that examined the normal reference range for alanine aminotransferase (ALT), studies that examined the relationship between ALT and nonalcoholic fatty liver disease, and those that assessed the significance of elevated liver chemistries on overall mortality and morbidity. The authors of the guideline graded each of their recommendations as strong with a very low level of evidence.

A summary of the recommendations is as follows:

• Clinicians should repeat the lab panel or perform a clarifying test before the initiation of evaluation of abnormal liver chemistries.
• Testing for chronic hepatitis C virus (HCV) is conducted with anti-HCV, and confirmation is performed with HCV-RNA by nucleic acid testing. Acute HCV testing is with anti-HCV and HCV-RNA by nucleic acid.
• Testing for chronic hepatitis B is conducted with hepatitis B surface antigen testing, and acute hepatitis B is conducted with hepatitis B surface antigen and immunoglobulin M anti-hepatitis B core antigen.
• Patients presenting with acute hepatitis and possible fecal-oral exposure should be tested for acute hepatitis A. Testing for acute hepatitis E should also be considered for patients returning from endemic areas and whose tests for acute hepatitis A, B, and C are negative.
• Patients who have elevated BMI and other symptoms of metabolic syndrome, including diabetes, obesity, hyperlipidemia, and hypertension, should undergo screening for nonalcoholic fatty liver disease.
• Women who consume more than 140 g per week of alcohol, and men who consume more than 210 g, who present with aspartate aminotransferase (AST)>ALT may be at risk for alcoholic liver disease and should be counseled for alcohol cessation.
• Patients who have abnormal liver chemistries without acute hepatitis should undergo testing for hereditary hemochromatosis with an iron level, transferring saturation, and serum ferritin. Patients with transferrin saturation ≥45% or elevated serum ferritin should receive hereditary hemochromatosis gene mutation analysis.
• Patients with abnormal AST and ALT levels should undergo testing for autoimmune liver disease, particularly if they have another autoimmune condition.
• Patients with persistently elevated AST and ALT levels should undergo screening for Wilson's disease with serum ceruloplasmin testing, particularly if they are <55 years of age. In the setting of low ceruloplasmin, testing should be confirmed with 24-hour urinary copper and slit-lamp eye examination to identify pathognomonic Kayser-Fleischer rings.
• Patients with persistently elevated AST and ALT levels should undergo screening for alpha-1 anti-trypsin deficiency with alpha-1 anti-trypsin phenotype.
• Clinicians should ask patients who have abnormal liver chemistries about prescription and over-the-counter medications, nonprescribed complementary or alternative medicines, and dietary or herbal supplements that may be associated with drug-induced liver injury.
• Clinicians should consider a liver biopsy when serologic testing and imaging fails to determine a diagnosis, to stage a condition, or when multiple diagnoses are possible.
• Elevation of alkaline phosphatase should be confirmed with an elevation in gamma-glutamyl transferase (GGT). Clinicians should avoid using GGT as a screening test for underlying liver disease in the absence of other abnormal liver chemistries.
• Patients with elevated alkaline phosphatase with or without elevated bilirubin should undergo testing for primary biliary cholangitis with testing for anti-mitochondrial antibody.
• Patients with elevated alkaline phosphatase with or without elevated bilirubin should undergo testing for primary sclerosing cholangitis with magnetic resonance cholangiography or endoscopic retrograde cholangio-pancreatography in conjunction with IgG4.
• Among patients with ALT or AST levels <5 times the upper limit of normal, clinicians should use patient history and laboratory testing to assess for viral hepatitis B and C, alcoholic and nonalcoholic fatty liver disease, hemochromatosis, Wilson's disease, alpha-1-anti-trypsin deficiency, and autoimmune hepatitis and consider drugs or supplement-related injury.
• Among patients with ALT or AST levels that are 5 to 15 times the upper limit of normal, clinicians should also assess for acute hepatitis A, B, and C in addition to all etiologies for ALT/AST elevation <5 times the upper limit of normal.
• Among patients with ALT or AST levels >15 times the upper limit of normal or with massive elevated ALT >10,000 IU/I, clinicians should assess for acetaminophen toxicity and ischemic hepatopathy.
• Patients who present with acute hepatitis with an elevated prothrombin time or encephalopathy require immediate referral to a liver specialist.
  

Reference

• Kwo PY, Cohen SM, Lim JK. ACG Clinical Guideline: Evaluation of abnormal liver chemistries. Am J Gastroenterol. 2017;112:18-35. doi:10.1038/ajg.2016.517
  

StephenW

评估异常肝化学：临床指南


ACG已经发布了用于诊断和评估肝脏测试结果异常的患者的优选方法的建议。
ACG已经发布了用于诊断和评估肝脏测试结果异常的患者的优选方法的建议。

美国胃肠病学会（ACG）已经发布了关于异常肝化学评价的临床实践指南。

研究人员审查了MEDLINE和EMBASE数据库中关于异常肝化学的评估的证据，研究了丙氨酸氨基转移酶（ALT）的正常参考范围的研究，研究了ALT和非酒精性脂肪肝病之间的关系，升高的肝化学对总死亡率和发病率的意义。该指南的作者将他们的每个建议分成了很强的，证据非常低的证据。



建议摘要如下：

    临床医生应该在开始评估异常肝脏化学物质之前重复实验室小组或进行澄清测试。
    用抗HCV进行慢性丙型肝炎病毒（HCV）的测试，并通过核酸测试用HCV-RNA进行确认。急性HCV测试是通过核酸与抗HCV和HCV-RNA。
    慢性乙型肝炎的测试用乙型肝炎表面抗原测试进行，急性乙型肝炎用乙型肝炎表面抗原和免疫球蛋白M抗乙型肝炎核心抗原进行。
    急性肝炎和可能的粪便口服暴露的患者应进行急性甲型肝炎检查。对于从流行地区返回的急性乙型肝炎，急性甲型肝炎，急性甲型肝炎，丙型肝炎和丙型肝炎的检测为阴性的，应考虑进行急性乙型肝炎的检测。
    具有升高的BMI和代谢综合征的其它症状（包括糖尿病，肥胖症，高脂血症和高血压）的患者应经历非酒精性脂肪性肝病的筛查。
    每周消耗超过140g酒精的女性和消耗超过210g的男性，其天门冬氨酸转氨酶（AST）> ALT的患者可能面临酒精性肝病的风险，应接受酒精戒断的建议。
    具有非急性肝炎的异常肝化学的患者应该接受具有铁水平，转移饱和度和血清铁蛋白的遗传性血色素沉着症的测试。转铁蛋白饱和度≥45％或升高的血清铁蛋白患者应接受遗传性血色素沉着基因突变分析。
    具有异常AST和ALT水平的患者应进行自身免疫性肝病的测试，特别是如果他们有另一种自身免疫性疾病。
    持续升高的AST和ALT水平的患者应该用血清铜蓝蛋白试验来检查Wilson病，特别是如果他们<55岁。在低血浆铜蓝蛋白的设置中，应该用24小时尿铜和裂隙灯眼睛检查来确认测试，以鉴定病理性Kayser-Fleischer环。
    持续升高的AST和ALT水平的患者应该进行α-1抗胰蛋白酶缺乏与α-1抗胰蛋白酶表型的筛选。
    临床医生应该询问处方和非处方药物，非处方补充或替代药物以及可能与药物诱发的肝损伤相关的饮食或草药补充剂的肝脏化学异常的患者。
    当血清学测试和成像无法确定诊断，分期或可能进行多个诊断时，临床医生应考虑肝活检。
    碱性磷酸酶的升高应该用γ-谷氨酰转移酶（GGT）的升高来确认。临床医生应避免使用GGT作为基础肝脏疾病的筛查测试，没有其他异常肝脏化学。
    具有或不具有升高的胆红素的升高的碱性磷酸酶的患者应经受用于抗线粒体抗体测试的原发性胆汁性胆管炎的测试。
    具有或不具有升高的胆红素的升高的碱性磷酸酶的患者应当与磁共振胆管造影术或内镜逆行胆管 - 胰腺造影术结合IgG4进行原发性硬化性胆管炎的测试。
    在ALT或AST水平<正常上限5倍的患者中，临床医生应使用患者病史和实验室检查来评估病毒性乙型肝炎和丙型肝炎，酒精性和非酒精性脂肪性肝病，血色沉着病，威尔逊氏病，α-1-胰蛋白酶缺乏症和自身免疫性肝炎，并考虑药物或补充剂相关的损伤。
在ALT或AST水平为正常上限5-15倍的患者中，临床医生还应评估急性甲型肝炎，乙型和丙型肝炎以及ALT / AST升高<5倍正常上限的病因 。
     在ALT或AST水平>正常上限的15倍或具有大量升高的ALT> 10,000IU / I的患者中，临床医生应评估对乙酰氨基酚毒性和缺血性肝病。
     存在急性肝炎的凝血酶原时间或脑病升高的患者需要立即转诊给肝脏专科医生。

参考

     Kwo PY，Cohen SM，Lim JK。 ACG临床指南：异常肝化学的评价。 Am J Gastroenterol。 2017; 112：18-35。 doi：10.1038 / ajg.2016.517