Tuesday, September 24, 2013

Diagnosing and Managing Hepatic Disease in the Primary Care Setting

In a conference in Boston, specialists discussed the utility of laboratory tests and diagnostic procedures used to evaluate liver disease, and presented a number of case studies so the audience could relate the concepts to their own practice.

The specialists showed several pictures of diseased livers from their practice (eg, hepatic hemangioma, vascular structures, rupture of an umbilical hernia). These cases included a self-described “social drinker” with hepatomegaly, a chronic alcoholic with a recent history of headaches, and a patient that had consumed too much acetaminophen. 

While discussing the topic of serum aminotransferases, one of the case studies showed a patient in whom AST (aspartate aminotransferase) and ALT (alanine aminotransferase) were elevated, yet the liver biopsy was normal. In a case such as this, it was mentioned that the case was a suspect of muscle source and the case was that of a body builder. This was the first example  provided of the “MCAT” acronym for remembering four causes of unexplained ALT elevations: muscle/disease/injury (CPK, creatine phosphokinase), celiac sprue (TTG antibody, tissue transglutaminase), adrenal insufficiency (cortisol), and thyroid dysfunction (TSH, thyroid-stimulating hormone).

The experts advised primary care physicians to look at the patient’s palms for the stigmata of chronic liver disease, such as palmar erythema. They suggested to also look for “paper money skin” skin (ie, telangiectasias). Additionally, they said that ophthalmologists need to get involved in diagnosis and screening for liver disease (eg, the Kayser-Fleischer Ring eye findings in Wilson’s Disease), telling the audience that “You and I would miss it.” While a liver biopsy is considered to be the best test for liver disease, it is invasive and subject to complications. Non-invasive alternatives for evaluating the degree of hepatic fibrosis (or hepatic stiffness) include Fibrotest (Fibrosure) and Fibroscan, which are useful because whereas a liver biopsy samples only 1/50,000th of the whole liver, these tests sample 1/500th of the whole liver.


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