Differentiating between autoimmune hepatitis, primary biliary cirrhosis and overlap syndrome

Size: px
Start display at page:

Download "Differentiating between autoimmune hepatitis, primary biliary cirrhosis and overlap syndrome"

Transcription

1 Differentiating between autoimmune hepatitis, primary biliary cirrhosis and overlap syndrome Dong Hyun Sinn, M.D., Ph.D. Department of Medicine, Samsung Medical Center Sungkyunkwan University School of Medicine, Seoul, Korea

2 Contents Why is differentiation necessary? Why is differentiation difficult? How can we differentiate?

3 AIH: pathogenesis T-cell mediated immune attack Un-resolving inflammation of the liver Kriese et al., Frontline Gastroenterology 2013;4:2 Manns et al., AASLD practice guideline 2010

4 Characteristics Circulating autoantibodies Elevated immunoglobulins Dramatic response to immune suppression Jeong SH, KASL meeting 2011:S44

5 Autoantibodies Manns et al., AASLD practice guideline 2010

6 Histology Manns et al., AASLD practice guideline 2010

7 Diagnosis Manns et al., AASLD practice guideline 2010

8 Characteristics of AIH in Korean Mean age = 52.8 years (19-87) 88% female Multicenter, 343 patients Mostly type I AIH Presentation Asymptomatic (30.6%) Cirrhotic (22.7%) Decompensation (4.3%) Kim BH et al., J Gastroenterol Hepatol 2013;28:128

9 Characteristics of AIH in Korean Single-center, 86 patients Mean age: 51 years (17 79 years) Female: 83.7% Presentation Asymptomatic (37.2%) Jaundice (45.3%) Fatigue (16.3%) Kil JS et al., J Korean Med Sci 2010;25:54

10 Characteristics of AIH in Korean Single-center, 62 patients Mean age: 50 years (20 76) Female: 90% Presentation Indistinguishable from acute viral hepatitis (constitutional symptoms, anorexia, nausea, and jaundice): 37% Liver failure (3%) Cirrhosis (23%) Lim YS et al., J Hepatol 2008;48:133

11 PBC: pathogenesis Damage and loss of biliary epithelial cells lining small intrahepatic bile ducts Chronic cholestatic liver disease Jones Gut 2007;56:1615

12 Histology Kaplan et al., N Engl J Med 2005;353:1261

13 Diagnosis 1. Biochemical evidence of cholestasis based mainly on alkaline phosphatase elevation. 2. Presence of AMA 3. Histologic evidence of nonsuppurative destructive cholangitis and destruction of interlobular bile ducts When two of the three criteria are met, the diagnosis of PBC can be established Lindor et al., AASLD Practice guideline, 2010

14 Characteristics of PBC in Korea Multicenter, 251 patients Age = 55 Female = 87% Presentation Asymptomatic = 61% Systemic symptoms = 27% Decompensation = 12% AMA positive = 98% Jung HE et al., Clin Mol Hepatol 2012;18:375

15 AIH-PBC overlap syndrome AIH PBC AIH ALT > 5 X UNL IgG > 2 X UNL, ASM (+) Compatible liver biopsy PBC AP > 2 X UNL or rgt > 5 X UNL AMA 1:40 Compatible liver biopsy

16 Characteristics of PBC in Korea Single center, 24 patients Age = 50 years Female = 95.8% Presentation Asymptomatic = 56% Pruritus = 29% Jaundice = 25% AIH overlap syndrome = 5/24 (20.8%) Jung HE et al., Clin Mol Hepatol 2012;18:375

17 Contents Why is differentiation necessary? Why is differentiation difficult? How can we differentiate?

18 Why is differentiation necessary? Different treatment AIH: steroid and/or azathioprine PBC: UDCA Treatment with potential side effects

19 Treatment-related side effects from AIH Manns et al., AASLD practice guideline 2010

20 Side effects can be fatal F/58 Known DM Abnormal LFT Bilirubin: 3.7, AST/ALT: 423/541 Liver biopsy: interface hepatitis, periportal fibrosis, moderate lobular and porto-poriportal activity Serum IgG = 2500 ANA = 1:40, anti-sm = positive Steroid + Azathioprine started LFT improved (bilirubin: 2.5, AST/ALT: 44/151) Discharged

21 Side effects can be fatal 20 days after discharge Presented to emergency room with fever, diarrhea CBC: 330 (seg = 0%) k Bilirubin = 1.3, AST/ALT: 22/45 Septic shock (E.coli) Expired 8 days later due to multi-organ failure and septic shock.

22 What about high-dose UDCA? Well-tolerated drug Pares et al., Gastroenterology 2006;130:715

23 High-dose UDCA, potentially harmful? mg/kg/day for PSC Lindor et al., Hepatology 2009;50:808

24 Why is differentiation necessary? Treatment with rare, but serious side effects. Risk-benefit assessment.

25 Contents Why is differentiation necessary? Why is differentiation difficult? How can we differentiate?

26 Autoimmune liver disease Represent about 5% of all chronic liver disease Sub-category Autoimmune hepatitis (AIH) Primary biliary cirrhosis (PBC) Primary sclerosing cholangitis (PSC) IgG4-associated cholangitis Etc Pathogenesis: unknown Diagnosis Based on reasonable exclusion + compatible findings No single test (eg., pathology) confirms the diagnosis Jeong SH, KASL meeting 2011:S44

27 Shared features PBC 8% Autoimmune Cholangitis 10% Autoimmune hepatitis 6% PSC 11% Chronic Hepatitis C 13% Cryptogenic Czaja et al., Ann Intern Med 1996;125:588

28 Overlap (?) with viral hepatitis 61/F 8 years ago, chronic hepatitis C diagnosed Rheumatoid arthritis Lab Genotype 2a/2c RNA: 30,780 copies/ml Peg-interferon + Ribavirin for 24 weeks

29 Course Peg-IFN + RBV IgG = 3441 mg/dl FANA = 1:320 Anti-SM = positive AMA = negative Bx = Active cirrhosis, etiology undetermined, marked activity Steroid + AZA AST ALT Pre_Tx ETR SVR 1m 4 years

30 Variant forms of AIH Syndrome Overlap syndromes AIH & PBC AIH & PSC AIH & viral hepatitis Distinguishing features Mitochondiral antibodies Histologic cholangitis Cholestatic laboratory changes Responsiveness to corticosteroid therapy Ulcerative colitis Histologic cholangitis Cholestatic laboratory changes Abnormal cholangiogram High autoantibody titer (AIH) Interface hepatitis, plasma cells (AIH) Low autoantibody titer (viral) Portal lymphoid aggregates, steatosis, bile duct injury (viral) Outlier syndrome Autoimmune cholangitis Cryptogenic chronic hepatitis AMA negative ANA, anti-sm positive Histologic features of bile duct injury Cholestatic laboratory changes Normal cholangiogram Absence of autoantibodies Histologic findings identical to AIH Responsiveness to cortocosteroid therapy Czaja et al., Ann Intern Med 1996;125:588

31 Consecutive PBC/AIH

32 AMA-negative PBC/AMA-positive AIH

33 Why is differentiation difficult? Diagnosis of exclusion Highly sensitive and specific test do not exist. Shared features Changing features

34 Scoring system for AIH Manns et al., AASLD practice guideline 2010

35 Suk KT et al, Am J Gastroenterol 2012

36 Forms of etiology Suk KT et al, Am J Gastroenterol 2012

37 Drug-induced hepatitis vs. AIH Ju HY et al., Clin Mol Hepatol 2012;18:213

38 More concerns Nguyen et al., Hepatology 2008;47:1058

39 Scoring system for AIH Manns et al., AASLD practice guideline 2010

40 Differences in genetic susceptability Lim YS et al., J Hepatol 2008;48:133

41 Difference in autoantibodies 107 patients, Caucasian ANA (13%) Both (54%) SMA (33%) 343, multicenter study 1 ANA: 94% SMA: 23% Anti-LKM: 3% AMA: 11% 86, single center study 2 ANA: 81% SMA: 44% AMA: 3% 1 Kim BH et al., J Gastroenterol Hepatol 2013;28:128 Czaja., J Hepatology 1999;30:394 2 Kil JS et al., J Korean Med Sci 2010;25:54

42 Simplified score Hennes et al, Hepatology 2008;48:169

43 Initially recruited AIH patients from 21 university hospital (n = 480) Simplified criteria < Total Original criteria < (10%) (24%) 53 (15%) 224 > (9%) 52 (15%) 85 IAHG or simplified criteria (n = 343, 71.4%) Total 93 (27%) J Gastroenterol Hepatol 2013;28:128

44 Scoring system for AIH Manns et al., AASLD practice guideline 2010

45 Why if treatment response is incomplete? Kil JS et al., J Korean Med Sci 2010;25:54

46 Why is differentiation difficult? Diagnosis of exclusion Gold standard does not exist Few Korean data Clinical features can be shared or even may change

47 Contents Why is differentiation necessary? Why is differentiation difficult? How can we differentiate?

48 How can we differentiate? In any unexplained suspected liver disease (asymptomatic ~ liver failure), always think about the possibility of autoimmune liver disease. Use detailed history, serologic markers, laboratory patterns, histology and changes after time course, to differentiate the autoimmune liver disease.

49 Tools that can be used History Chronicity Drug, alcohol use Pattern of abnormal liver function tests Hepatocellular pattern? Cholestatic pattern? Autoantibiodies, immunoglobulins FANA, ASM, AMA, ANCA, IgG Liver biopsy

50 How? Disease presentation Asymptomatic Symptomatic (Failure) Manns et al., AASLD practice guideline 2010

51 Toxic vs. Autoimmune Disease presentation Asymptomatic Sometimes time tells the truth! Discontinuation of all drugs. Early withdrawal of immunosuppresive agents and watchful waiting for relapse.

52 How? Disease presentation AI-ALF Diagnostic criteria? Histologic features Symptomatic (Failure) Type 4,5 massive hepatic necrosis Lymphoid aggregates Central perivenulitis Plasma cell enrichment Stravitz et al., Hepatology 2011;53:517

53 Take home message Differentiating between autoimmune hepatitis, primary biliary cirrhosis and overlap syndrome Tools are used to differentiate History, lab pattern, autoantibodies, biopsy Clinical course Clinical suspicions is most important step in the differentiation!

Autoimmune Hepatitis. Hili N. Morillas, MD November 1, 2004 Morning Report

Autoimmune Hepatitis. Hili N. Morillas, MD November 1, 2004 Morning Report Autoimmune Hepatitis Hili N. Morillas, MD November 1, 2004 Morning Report Definition! An unresolving inflammation of unknown cause.! Characterized by the presence of interface hepatitis and portal plasma

More information

Autoimmune Hepatitis. Stephan Kanzler II. Department of Medicine Leopoldina Hospital Schweinfurt, Germany

Autoimmune Hepatitis. Stephan Kanzler II. Department of Medicine Leopoldina Hospital Schweinfurt, Germany Autoimmune Hepatitis Stephan Kanzler II. Department of Medicine Leopoldina Hospital Schweinfurt, Germany Falk Symposium 160, Portoroz - 16.06.2007 Autoimmune Liver Diseases AIH OVERLAP PBC/ PSC Autoimmune

More information

Overlap Syndromes U.Leuschner Internistisches Facharztzentrum Frankfurt am Main, Germany XIII Falk Liver Week October 6 11, 2006 Freiburg, Germany

Overlap Syndromes U.Leuschner Internistisches Facharztzentrum Frankfurt am Main, Germany XIII Falk Liver Week October 6 11, 2006 Freiburg, Germany Overlap Syndromes U.Leuschner Internistisches Facharztzentrum Frankfurt am Main, Germany XIII Falk Liver Week October 6 11, 2006 Freiburg, Germany Definition of Overlap Syndromes (OLS) There is no unequivocal

More information

Drugs Believed Capable of Inducing Autoimmune Hepatitis

Drugs Believed Capable of Inducing Autoimmune Hepatitis Drugs Believed Capable of Inducing Autoimmune Hepatitis Leonard B. Seeff, M.D. National Institutes of Diabetes and Digestive and Kidney Diseases National Institutes of Health Immune-Mediated Liver Diseases

More information

Steatohepatitis Grading. Bile Duct Lesions

Steatohepatitis Grading. Bile Duct Lesions Common Problems in Hepatopathology Steatohepatitis Grading & Bile Duct Lesions Larry Burgart, MD Abbott NW Hospital, Minneapolis University of Minnesota Inflammatory Liver Disease Lawrence Burgart, M.D.

More information

Management of Cholestatic Liver Diseases MANAGEMENT OF PBC/PSC

Management of Cholestatic Liver Diseases MANAGEMENT OF PBC/PSC Management of Cholestatic Liver Diseases Kris V. Kowdley MD FACG Director, Liver Center of Excellence Virginia Mason Medical Center Seattle, WA MANAGEMENT OF PBC/PSC Epidemiology Natural history Diagnosis

More information

Autoimmune Hepatitis SG MAITY. 420 Medicine Update

Autoimmune Hepatitis SG MAITY. 420 Medicine Update 420 Medicine Update 73 Autoimmune Hepatitis SG MAITY During the past three decades, remarkable advances have taken place in the understanding of epidemiology, natural history and pathogenesis of chronic

More information

Elevated Liver Enzymes Workup, When to Worry, When to Refer

Elevated Liver Enzymes Workup, When to Worry, When to Refer Elevated Liver Enzymes Workup, When to Worry, When to Refer Ontario College of Family Physicians Annual Scientific Assembly Barry Lumb No disclosures Liver Biochemistry Bilirubin Hepatocellular - AST,

More information

HEPATITIS C DIAGNOSIS AND MANAGEMENT

HEPATITIS C DIAGNOSIS AND MANAGEMENT HEPATITIS C DIAGNOSIS AND MANAGEMENT Introduction The hepatitis C virus (HCV) is one of six viruses (A, B, C, D, E, G) that account for the majority of cases of viral hepatitis. It is responsible for about

More information

Autoimmune Hepatitis- Better

Autoimmune Hepatitis- Better Autoimmune Hepatitis- Better Understanding 9 : 3 SG Maity, Kolkata Introduction & Definition Autoimmune Hepatitis () is generally considered un-resolving inflammation of liver of unknown cause. Pathologic

More information

Autoimmune Hepatitis and Overlap Syndrome

Autoimmune Hepatitis and Overlap Syndrome Autoimmune Hepatitis and Overlap Syndrome Tram T. Tran, MD, FACG Medical Director, Liver Transplant Associate Professor of Medicine Cedars Sinai Medical Center Autoimmune Hepatitis Demographics and Epidemiology

More information

Endoscopy in Primary Sclerosing Cholangitis. Stephen M. Lange M.D. Mayo Clinic Jacksonville, FL

Endoscopy in Primary Sclerosing Cholangitis. Stephen M. Lange M.D. Mayo Clinic Jacksonville, FL Endoscopy in Primary Sclerosing Cholangitis Stephen M. Lange M.D. Mayo Clinic Jacksonville, FL Goals Role of ERCP in PSC Initial Diagnosis Complications Managing procedure risks Role of MRCP Endoscopic

More information

Overlap syndromes: The International Autoimmune Hepatitis Group (IAIHG) position statement on a controversial issue

Overlap syndromes: The International Autoimmune Hepatitis Group (IAIHG) position statement on a controversial issue Position Paper Overlap syndromes: The International Autoimmune Hepatitis Group (IAIHG) position statement on a controversial issue Kirsten Muri Boberg 1,, Roger W. Chapman 2, Gideon M. Hirschfield 3, Ansgar

More information

Autoimmune Hepatitis. DEIRDRE KELLY ESPGHAN GOES TO AFRICA CAPETOWN October 2013

Autoimmune Hepatitis. DEIRDRE KELLY ESPGHAN GOES TO AFRICA CAPETOWN October 2013 Autoimmune Hepatitis DEIRDRE KELLY ESPGHAN GOES TO AFRICA CAPETOWN October 2013 Autoimmune Hepatitis DEFINITION Progressive necroinflammatory disease Mononuclear infiltrate in the portal tract Increase

More information

Evaluation of Liver Function tests in Primary Care. Abid Suddle Institute of Liver Studies, KCH

Evaluation of Liver Function tests in Primary Care. Abid Suddle Institute of Liver Studies, KCH Evaluation of Liver Function tests in Primary Care Abid Suddle Institute of Liver Studies, KCH Liver Function tests Markers of hepatocellular damage Cholestasis Liver synthetic function Markers of Hepatocellular

More information

Autoimmune Hepatitis. What is autoimmune hepatitis? Autoimmune hepatitis affects the liver.

Autoimmune Hepatitis. What is autoimmune hepatitis? Autoimmune hepatitis affects the liver. Autoimmune Hepatitis What is autoimmune hepatitis? Autoimmune hepatitis affects the liver. Autoimmune hepatitis is a disease in which the body s immune system attacks liver cells. This immune response

More information

Autoimmune Pancreatitis: When to suspect How to Diagnose and How to Treat

Autoimmune Pancreatitis: When to suspect How to Diagnose and How to Treat Autoimmune Pancreatitis: When to suspect How to Diagnose and How to Treat Suresh T. Chari, MD Head, Pancreas Interest Group Professor, Division of Gastroenterology & Hepatology Mayo Clinic College of Medicine,

More information

Approach to Abnormal Liver Tests

Approach to Abnormal Liver Tests Approach to Abnormal Liver Tests Naga P. Chalasani, MD, FACG Professor of Medicine and Cellular & Integrative Physiology Director, Division of Gastroenterology and Hepatology Indiana University School

More information

Abnormal Liver Tests and Fatty Liver Disease

Abnormal Liver Tests and Fatty Liver Disease Abnormal Liver Tests and Fatty Liver Disease Michael D Voigt MD Medical Director Liver Failure and Transplantation, University of Iowa Hospital and Clinics Conflict of interest: I sadly have nothing to

More information

Alcoholic and Non-Alcoholic Fatty Liver Disease

Alcoholic and Non-Alcoholic Fatty Liver Disease Alcoholic and Non-Alcoholic Fatty Liver Disease Thomas W. Faust, M.D., M.B.E. Professor of Clinical Medicine Division of Gastroenterology The University of Pennsylvania Alcoholic Liver Disease Additional

More information

Patterns of abnormal LFTs and their differential diagnosis

Patterns of abnormal LFTs and their differential diagnosis Patterns of abnormal LFTs and their differential diagnosis Professor Matthew Cramp South West Liver Unit and Peninsula Schools of Medicine and Dentistry, Plymouth Summary liver function / liver function

More information

GI & Liver Disease Testing By Doctors For Doctors

GI & Liver Disease Testing By Doctors For Doctors GI & Liver Disease Testing By Doctors For Doctors Updated September 2013 GI & Liver Disease Panels Autoimmune GI Panels Inflammatory Bowel Disease Panel RDL s Inflammatory Bowel Disease (IBD) Panel combines

More information

Autoimmune Hepatitis. Autoimmune Disease

Autoimmune Hepatitis. Autoimmune Disease Autoimmune Hepatitis Autoimmune Hepatitis Autoimmune hepatitis is a disease in which the body's immune system attacks liver cells. This causes the liver to become inflamed (hepatitis). Researchers think

More information

Primary Biliary Cirrhosis and Primary Sclerosing Cholangitis

Primary Biliary Cirrhosis and Primary Sclerosing Cholangitis Primary Biliary Cirrhosis and Primary Sclerosing Cholangitis Claudia O. Zein, MD, MSc Digestive Disease Institute Cleveland Clinic Chronic Cholestatic Liver Disease in Adults Primary bile duct disorders

More information

NP/PA Clinical Hepatology Fellowship Summary of Year-Long Curriculum

NP/PA Clinical Hepatology Fellowship Summary of Year-Long Curriculum OVERVIEW OF THE FELLOWSHIP The goal of the AASLD NP/PA Fellowship is to provide a 1-year postgraduate hepatology training program for nurse practitioners and physician assistants in a clinical outpatient

More information

What to Do with the Patient With Abnormal Liver Enzymes? Nizar N. Zein, M.D. The Cleveland Clinic

What to Do with the Patient With Abnormal Liver Enzymes? Nizar N. Zein, M.D. The Cleveland Clinic What to Do with the Patient With Abnormal Liver Enzymes? Nizar N. Zein, M.D. The Cleveland Clinic Introduction Elevated liver enzymes is often not a clinical problem by itself. However it is a warning

More information

Alanine aminotransferase test

Alanine aminotransferase test Alanine aminotransferase test Also known as: Serum glutamic-pyruvic transaminase, SGPT or ALT The alanine aminotransferase test, also known as ALT, is one of a group of tests known as liver function tests

More information

Hepatitis. Objectives. General term for inflammation of the liver. Can be due to non-infectious causes such as:

Hepatitis. Objectives. General term for inflammation of the liver. Can be due to non-infectious causes such as: Laboratory Diagnosis & Monitoring of Infectious Hepatitis Objectives Compare and contrast the major types of hepatitis viruses and explain the disease transmission and progression processes in viral hepatitis

More information

Liver transplantation in primary cholestatic liver diseases. Transplant forum 19/1/2011 Swastik Agarwal

Liver transplantation in primary cholestatic liver diseases. Transplant forum 19/1/2011 Swastik Agarwal Liver transplantation in primary cholestatic liver diseases Transplant forum 19/1/2011 Swastik Agarwal Cholestatic indications for OLT Pediatric Alagille syndrome PFIC Non-syndromic biliary hypoplasia

More information

HBV: Update and Treatment Guidelines

HBV: Update and Treatment Guidelines HBV: Update and Treatment Guidelines Virginia Clark, MD, MS Assistant Professor of Medicine Division of Gastroenterology, Hepatology, and Nutrition University of Florida Learning Objective Identify the

More information

The Normal Liver. Acinar/lobular architecture Portal tracts Hepatic plates & sinusoids Central veins

The Normal Liver. Acinar/lobular architecture Portal tracts Hepatic plates & sinusoids Central veins Harvard-MIT Division of Health Sciences and Technology HST.121: Gastroenterology, Fall 2005 Instructors: Dr. Jonathan Glickman The Normal Liver Acinar/lobular architecture Portal tracts Hepatic plates

More information

Update on Hepatitis C. Sally Williams MD

Update on Hepatitis C. Sally Williams MD Update on Hepatitis C Sally Williams MD Hep C is Everywhere! Hepatitis C Magnitude of the Infection Probably 8 to 10 million people in the U.S. are infected with Hep C 30,000 new cases are diagnosed annually;

More information

Liver Pathology Questions. Matthew M. Yeh, MD, PhD. 1. Which of the following statements is true regarding hepatitis B?

Liver Pathology Questions. Matthew M. Yeh, MD, PhD. 1. Which of the following statements is true regarding hepatitis B? Liver Pathology Questions 2012 Matthew M. Yeh, MD, PhD 1. Which of the following statements is true regarding hepatitis B? A. Cirrhosis is not a prerequisite for the development of hepatocellular carcinoma.

More information

Case 1: Acute Hepatitis C Virus (HCV) Infection. Learning Objectives. Case 1: Chief Complaint

Case 1: Acute Hepatitis C Virus (HCV) Infection. Learning Objectives. Case 1: Chief Complaint Slide 1 of 29 Case 1: Acute Hepatitis C Virus (HCV) Infection Robert T. Schooley, MD Professor and Vice Chair of Medicine University of California San Diego FORMATTED: 04-18-13 Learning Objectives Slide

More information

Peg-IFN and ribavirin: what sustained virologic response can be achieved by using HCV genotyping and viral kinetics?

Peg-IFN and ribavirin: what sustained virologic response can be achieved by using HCV genotyping and viral kinetics? Peg-IFN and ribavirin: what sustained virologic response can be achieved by using HCV genotyping and viral kinetics? Prof. I. Bakulin Gastroenterology Department Key Questions Background Worldwide prevalence

More information

Wendy Carter, DO Medical Officer Division of Antiviral Products, FDA

Wendy Carter, DO Medical Officer Division of Antiviral Products, FDA Wendy Carter, DO Medical Officer Division of Antiviral Products, FDA Click to view Biosketch and Presentation Abstract or page down to review presentation Evaluation of Transaminase Elevations in Subjects

More information

Primary Care Approach to Diagnosis and Management of Chronic Hepatitis C Brian Viviano, D.O.

Primary Care Approach to Diagnosis and Management of Chronic Hepatitis C Brian Viviano, D.O. Primary Care Approach to Diagnosis and Management of Chronic Hepatitis C Brian Viviano, D.O. Objectives Epidemiology of chronic hepatitis C CDC guidelines on screening or hepatitis C Diagnosing hepatitis

More information

Liver Enzymes. AST and ALT (Transaminases)

Liver Enzymes. AST and ALT (Transaminases) Liver Enzymes Four separate liver enzymes are included on most routine laboratory tests. They are- aspartate aminotransferase (AST or SGOT) and alanine aminotransferase (ALT or SGPT), which are known together

More information

LIVER FUNCTION TESTS AND STATINS

LIVER FUNCTION TESTS AND STATINS LIVER FUNCTION TESTS AND STATINS Philippe J. Zamor and Mark W. Russo Current Opinion in Cardiology 2011,26:338 341 SUMMARY Purpose of review: To discuss recent data on statins in patients with elevated

More information

IgG4 related Cholangiopathy and Pancreatitis

IgG4 related Cholangiopathy and Pancreatitis IgG4 related Cholangiopathy and Pancreatitis Dhiraj Yadav, MD MPH Associate Professor Division of Gastroenterology & Hepatology University of Pittsburgh PSC Meeting, Pittsburgh April 26-28, 2013 Some publications

More information

Pathophysiology. Asst. Prof. Dr. Dalya Basil. Disorders of GIT and Hepatobiliary System

Pathophysiology. Asst. Prof. Dr. Dalya Basil. Disorders of GIT and Hepatobiliary System Pathophysiology Lecture 15 Asst. Prof. Dr. Dalya Basil Disorders of GIT and Hepatobiliary System Viral Hepatitis: is a liver inflammation caused by five unrelated hepatotropic viruses Hepatitis A, Hepatitis

More information

Update on PROGRESS (PSC Resource of Genetic Risk, Environment and Synergy Studies)

Update on PROGRESS (PSC Resource of Genetic Risk, Environment and Synergy Studies) Update on PROGRESS (PSC Resource of Genetic Risk, Environment and Synergy Studies) Konstantinos N. Lazaridis, MD, FACP Associate Professor of Medicine Mayo Clinic College of Medicine Rochester, MN Rationale

More information

Jaundice. Michael Ornes

Jaundice. Michael Ornes Jaundice Michael Ornes Definitions Jaundice: hyperbilirubinemia leading to yellow discoloration of the skin Icterus: hyperbilirubinemia leading to yellow discoloration of the sclera Usually undetectable

More information

Autoimmune Hepatitis: When First Line Therapy Does Not Work

Autoimmune Hepatitis: When First Line Therapy Does Not Work Autoimmune Hepatitis: When First Line Therapy Does Not Work John M. Vierling, M.D., F.A.C.P. Professor of Medicine and Surgery Chief of Hepatology Director of Advanced Liver Therapies Baylor College of

More information

Management of hepatitis C: pre- and post-liver transplantation. Piyawat Komolmit Bangkok

Management of hepatitis C: pre- and post-liver transplantation. Piyawat Komolmit Bangkok Management of hepatitis C: pre- and post-liver transplantation Piyawat Komolmit Bangkok Liver transplantation and CHC Cirrhosis secondary to HCV is the leading cause of liver transplantation in the US

More information

Autoimmune Pancreatitis Presenting with Jaundice

Autoimmune Pancreatitis Presenting with Jaundice Autoimmune Pancreatitis Presenting with Jaundice Salil Garg, Harvard Medical School, Year III Gillian Lieberman, M.D. Our patient: A 73 yo male presenting with obstructive jaundice, history of autoimmune

More information

Detection and Assessment of Drug Induced Liver Injury (DILI) in NASH Clinical Trials. Key Questions and Future Challenges.

Detection and Assessment of Drug Induced Liver Injury (DILI) in NASH Clinical Trials. Key Questions and Future Challenges. Detection and Assessment of Drug Induced Liver Injury (DILI) in NASH Clinical Trials. Key Questions and Future Challenges. Arie Regev, MD Global Patient Safety Eli Lilly and Company 1 Outline Background

More information

Hepatitis E virus and chronic hepatitis in organ-transplant recipients

Hepatitis E virus and chronic hepatitis in organ-transplant recipients Hepatitis E virus and chronic hepatitis in organ-transplant recipients Nassim Kamar MD, PhD Department of Nephrology, Dialysis and Multi-Organ Transplantation Toulouse University Hospital Antwerp, 13/3/2009

More information

Evaluation of abnormal LFT in the asymptomatic patient. Son Do, M.D. Advanced Gastroenterology Vancouver, WA

Evaluation of abnormal LFT in the asymptomatic patient. Son Do, M.D. Advanced Gastroenterology Vancouver, WA Evaluation of abnormal LFT in the asymptomatic patient Son Do, M.D. Advanced Gastroenterology Vancouver, WA Definition of chronic, abnormally elevated LFT Elevation of one or more of the following for

More information

PREGNANCY AND THE LIVER

PREGNANCY AND THE LIVER Imtiaz Alam, M.D. Phone: [512] 719-4370 Mandy Mishra, CNS Fax: [512] 719-4371 Austin Hepatitis Center 12201, Renfert Way Suite 235 Austin, TX 78758 PREGNANCY AND THE LIVER How does pregnancy affect the

More information

Autoimmune Liver Disease

Autoimmune Liver Disease Autoimmune Liver Disease Heiner Wedemeyer, MD and Michael P. Manns, MD Hannover Medical School Hannover, Germany Key Concepts The diagnosis of autoimmune hepatitis is based on specific immunological, histological

More information

Emerging Approaches to PBC and PSC

Emerging Approaches to PBC and PSC Emerging Approaches to PBC and PSC Keith D. Lindor, MD, FACG Dean, College of Health Solutions Arizona State University OUTLINE PBC Epidemiology Diagnosis Treatment PSC Natural History Treatment Cancer

More information

Budesonide induces complete remission in autoimmune hepatitis

Budesonide induces complete remission in autoimmune hepatitis PO Box 2345, Beijing 100023, China World J Gastroenterol 2006 March 7; 12(9):1362-1366 World Journal of Gastroenterology ISSN 1007-9327 wjg@wjgnet.com 2006 The WJG Press. All rights reserved. VIRAL HEPATITIS

More information

Long Term Outcome of Primary Sclerosing Cholangitis

Long Term Outcome of Primary Sclerosing Cholangitis Diagnosis and Treatment of in Children Kenneth L. Cox, M.D. Pediatric Gastroenterology Lucile Packard Children s Hospital at Stanford University (PSC) In Children PSC is chronic inflammatory disease of

More information

Transmission of HCV in the United States (CDC estimate)

Transmission of HCV in the United States (CDC estimate) Transmission of HCV in the United States (CDC estimate) Past and Future US Incidence and Prevalence of HCV Infection Decline among IDUs Overall incidence Overall prevalence Infected 20+ years Armstrong

More information

Autoimmune Hepatitis

Autoimmune Hepatitis Autoimmune Hepatitis National Digestive Diseases Information Clearinghouse U.S. Department of Health and Human Services NATIONAL INSTITUTES OF HEALTH What is autoimmune hepatitis? Autoimmune hepatitis

More information

Non-alcoholic Fatty Liver Disease. Christi Matteoni, MD GI Consultants

Non-alcoholic Fatty Liver Disease. Christi Matteoni, MD GI Consultants Non-alcoholic Fatty Liver Disease Christi Matteoni, MD GI Consultants Definition of NAFLD Evidence of hepatic steatosis by imaging or histology No causes for secondary hepatic fat accumulation Significant

More information

PIERO LUIGI ALMASIO CATTEDRA DI GASTROENTEROLOGIA UNIVERSITA OF PALERMO

PIERO LUIGI ALMASIO CATTEDRA DI GASTROENTEROLOGIA UNIVERSITA OF PALERMO Steatosi e Steatoepatite PIERO LUIGI ALMASIO CATTEDRA DI GASTROENTEROLOGIA UNIVERSITA OF PALERMO Alcoholic liver disease Liver damage resulting from long-term alcohol consumption Histological features:

More information

Alanine aminotransferase (serum, plasma)

Alanine aminotransferase (serum, plasma) Alanine aminotransferase (serum, plasma) 1 Name and description of analyte 1.1 Name of analyte Alanine aminotransferase (ALT) 1.2 Alternative names Systematic name L alanine:2 oxoglutarate aminotransferase

More information

Goals of Therapy. Treatment Options for Hepatitis C. Patterns of Response. Progress in Hepatitis C Therapy

Goals of Therapy. Treatment Options for Hepatitis C. Patterns of Response. Progress in Hepatitis C Therapy Treatment Options for Hepatitis C Helen S. Te, M.D. Center for Liver Diseases University of Chicago Hospitals Chicago, Illinois Primary: To eliminate the virus Goals of Therapy Secondary: To decrease inflammation

More information

DISCLOSURE HEPATITIS C VIRUS: TEST, TREAT ASSESSMENT AND TREATMENT AND CURE PART 2: DIAGNOSTICS,

DISCLOSURE HEPATITIS C VIRUS: TEST, TREAT ASSESSMENT AND TREATMENT AND CURE PART 2: DIAGNOSTICS, HEPATITIS C VIRUS: TEST, TREAT AND CURE PART 2: DIAGNOSTICS, ASSESSMENT AND TREATMENT Tracy Swan Hepatitis/HIV Project Director Treatment Action Group DISCLOSURE Ms. Swan has no disclosures 1 LEARNING

More information

Review: How to work up your patient with Hepatitis C

Review: How to work up your patient with Hepatitis C Review: How to work up your patient with Hepatitis C You screened your patient, and now the HCV antibody test is positive. What do you do next? The antibody test only means they have been exposed to HCV.

More information

Cirrhosis and HCV. Jonathan Israel M.D.

Cirrhosis and HCV. Jonathan Israel M.D. Cirrhosis and HCV Jonathan Israel M.D. Outline Relationship of fibrosis and cirrhosisprevalence and epidemiology. Sequelae of cirrhosis Diagnosis of cirrhosis Effect of cirrhosis on efficacy of treatment

More information

LIVER FUNCTION ABNORMALITIES FALL INTO 2 MAIN GROUPS: 1) HEPATIC INJURY 2) CHOLESTATIC

LIVER FUNCTION ABNORMALITIES FALL INTO 2 MAIN GROUPS: 1) HEPATIC INJURY 2) CHOLESTATIC HEPATIC DISEASE LIVER FUNCTION ABNORMALITIES FALL INTO 2 MAIN GROUPS: 1) HEPATIC INJURY 2) CHOLESTATIC LFT s HEPATIC INJURY: ALT (5-40) AST (5-40) CHOLESTASIS: ALP (30-120) & GGT (5-65) (together) NONSPECIFIC

More information

Bile Duct Diseases and Problems

Bile Duct Diseases and Problems Bile Duct Diseases and Problems Introduction A bile duct is a tube that carries bile between the liver and gallbladder and the intestine. Bile is a substance made by the liver that helps with digestion.

More information

Virologic and serologic markers for the management of chronic hepatitis B patients

Virologic and serologic markers for the management of chronic hepatitis B patients Virologic and serologic markers for the management of chronic hepatitis B patients Michelle Martinot-Peignoux Service d Hépatologie Hôpital Beaujon UMR 1149 inserm-université Paris Diderot Clichy-France

More information

Treatment of Chronic Hepatitis B in an HBeAg Positive Patient

Treatment of Chronic Hepatitis B in an HBeAg Positive Patient Treatment of Chronic Hepatitis B in an HBeAg Positive Patient Adrián Gadano, MD Chief, Liver Unit - Hospital Italiano President, Fundación Icalma Buenos Aires - Argentina Case 1: History 52-year-old man.

More information

Title: Approaching the jaundiced patient Session No.: 1. Name: Maximilian Schöniger-Hekele Institution: Medical University of Vienna Country: Austria

Title: Approaching the jaundiced patient Session No.: 1. Name: Maximilian Schöniger-Hekele Institution: Medical University of Vienna Country: Austria Title: Approaching the jaundiced patient Session No.: 1 Name: Maximilian Schöniger-Hekele Institution: Medical University of Vienna Country: Austria Initial evaluation - Initial laboratory test Serum liver

More information

Evaluation of a Child with Elevated Transaminases. Linda V. Muir, M.D. April 11, 2008 Northwest Pediatric Liver Disease Symposium

Evaluation of a Child with Elevated Transaminases. Linda V. Muir, M.D. April 11, 2008 Northwest Pediatric Liver Disease Symposium Evaluation of a Child with Elevated Transaminases Linda V. Muir, M.D. April 11, 2008 Northwest Pediatric Liver Disease Symposium Disclosures I do not have a financial interest, arrangement or affiliation

More information

New Treatments for Hepatitis B and C

New Treatments for Hepatitis B and C New Treatments for Hepatitis B and C Bradford Waters M.D. Associate Professor of Medicine, University of Tennessee, Memphis Memphis VA Medical Center Hepatitis B In adults 90-95% of acute hepatitis B

More information

Rheumatology Labs for Primary Care Providers. Robert Monger, M.D., F.A.C.P. 2015 Frontiers in Medicine

Rheumatology Labs for Primary Care Providers. Robert Monger, M.D., F.A.C.P. 2015 Frontiers in Medicine Rheumatology Labs for Primary Care Providers Robert Monger, M.D., F.A.C.P. 2015 Frontiers in Medicine Objectives Review the Indications for and Interpretation of lab testing for the following diseases:

More information

Hepatitis A, B, C. This material is intended for insurance informational purposes only and is not personal medical advice for clients.

Hepatitis A, B, C. This material is intended for insurance informational purposes only and is not personal medical advice for clients. Hepatitis A, B, C Hepatitis is a general term referring to inflammation of the liver. The usual cause is viral, either Hepatitis A, B, or C. However, toxins and drugs may also induce a hepatitis. The onset

More information

Factors affecting drug metabolism

Factors affecting drug metabolism Faculty of Pharmacy- Clinical Pharmacy Program - level 5 - Spring 2016 o Gastroenterology 6th Lecture: Drugs and the liver o Prof.Dr. Nader El-Malky Professor of internal medicine, Gastroenterology & Hepatology

More information

Learning Objectives. Non-alcoholic Fatty Liver Disease (NAFLD) (Fatty Liver) What is Fatty Liver (Non-Alcoholic Fatty Liver)? Fatty Liver (NAFLD)

Learning Objectives. Non-alcoholic Fatty Liver Disease (NAFLD) (Fatty Liver) What is Fatty Liver (Non-Alcoholic Fatty Liver)? Fatty Liver (NAFLD) Learning Objectives Non-alcoholic Fatty Liver Disease (NAFLD) (Fatty Liver) Smruti R. Mohanty, MD, MS Assistant Professor of Medicine Center for Liver Diseases Section of Gastroenterology University of

More information

Promacta. Promacta (eltrombopag) Description

Promacta. Promacta (eltrombopag) Description Federal Employee Program 1310 G Street, N.W. Washington, D.C. 20005 202.942.1000 Fax 202.942.1125 5.10.15 Subject: Promacta Page: 1 of 6 Last Review Date: September 18, 2015 Promacta Description Promacta

More information

Adrenal Hormones. The adrenal-stress response: Adrenal Gland

Adrenal Hormones. The adrenal-stress response: Adrenal Gland Adrenal Hormones The adrenal-stress response: Adrenal Gland cortisol aldosterone Threat Response Cortisol Aldosterone Sugar = GLUCOcorticoid action -- cortisol Minerals (Na and K) = MINERALcorticoid action

More information

Work up of the Asymptomatic Patient with Liver Enzyme Abnormalities

Work up of the Asymptomatic Patient with Liver Enzyme Abnormalities Work up of the Asymptomatic Patient with Liver Enzyme Abnormalities G.Y. Minuk Professor of Medicine and Pharmacology University of Manitoba Head, Section of Hepatology Health Sciences Centre 2014 NDAFP

More information

The Impact of Curing HCV

The Impact of Curing HCV The Impact of Curing HCV on the Liver and the Extra-hepatic ti Manifestation of Chronic HCV Mitchell L. Shiffman, MD, FACG Director Liver Institute of Virginia Bon Secours Health System Richmond and Newport

More information

Non-alcoholic Fatty liver disease in children. Dr.S.Venkatesh Karthik Consultant Paediatric Hepatologist KTP-NUCMI, NUH, Singapore

Non-alcoholic Fatty liver disease in children. Dr.S.Venkatesh Karthik Consultant Paediatric Hepatologist KTP-NUCMI, NUH, Singapore Non-alcoholic Fatty liver disease in children Dr.S.Venkatesh Karthik Consultant Paediatric Hepatologist KTP-NUCMI, NUH, Singapore Relevance Leading cause of chronic liver disease- both adults and children

More information

Autoimmune Liver Disease in Children

Autoimmune Liver Disease in Children Distinguished Academician Lecture 2001 239 Autoimmune Liver Disease in Children G Mieli-Vergani,*PhD, FRCP, FRCPCH, D Vergani,**PhD, FRCPath, FRCP Abstract Autoimmune liver disorders are characterised

More information

Chronic Hepatitis/Chronic Active Hepatitis in Dogs

Chronic Hepatitis/Chronic Active Hepatitis in Dogs Chronic Hepatitis/Chronic Active Hepatitis in Dogs Robert M. Hardy, DVM, MS, Diplomate ACVIM (Internal Medicine) Department of Small Animal Clinical Sciences College of Veterinary Medicine University of

More information

Approach to the Patient with Abnormal Liver Tests

Approach to the Patient with Abnormal Liver Tests Approach to the Patient with Abnormal Liver Tests Alvaro Koch, M.D. Associate Professor of Medicine Medical Director, Liver Transplantation Program Division of Digestive Diseases & Nutrition University

More information

HIV and Hepatitis C NORTHWEST AIDS EDUCATION AND TRAINING CENTER

HIV and Hepatitis C NORTHWEST AIDS EDUCATION AND TRAINING CENTER NORTHWEST AIDS EDUCATION AND TRAINING CENTER HIV and Hepatitis C John Scott, MD, MSc Assistant Professor University of Washington, Department of Medicine Presentation prepared by: John Scott, MD, MSc and

More information

Autoimmune Liver Disease and Primary Sclerosing Cholangitis

Autoimmune Liver Disease and Primary Sclerosing Cholangitis OTC - King Faisal Specialist Hospital and Research Center Riyadh Autoimmune Liver Disease and Primary Sclerosing Cholangitis M. Burdelski Paper case I: D.G.* 13.10.86 (male) 16 months : diabetes mell.

More information

Hepatitis B-Understanding Your Disease, Symptoms, and Lab Results An Informative Overview by Monica Buelt

Hepatitis B-Understanding Your Disease, Symptoms, and Lab Results An Informative Overview by Monica Buelt Hepatitis B-Understanding Your Disease, Symptoms, and Lab Results An Informative Overview by Monica Buelt Hepatitis B is a disease of the liver caused by the Hepatitis B virus (A.D.A.M. Editorial, 2012).

More information

Subproject 4: Specification and Documentation of Metabolic and Neoplastic Diseases

Subproject 4: Specification and Documentation of Metabolic and Neoplastic Diseases Subproject 4: Specification and Documentation of Metabolic and Neoplastic Diseases M. Trauner, Division of Gastroenterology and Hepatology, Department of Internal Medicine, MUG Co- Investigator: H. Samonigg,

More information

Dr Lee Yin Mei Senior Consultant Gastroenterology NUHS

Dr Lee Yin Mei Senior Consultant Gastroenterology NUHS Dr Lee Yin Mei Senior Consultant Gastroenterology NUHS Simple steatosis (SS), through steatohepatitis Put picture of spectrum Prevalence of NASH 3-25% NASH Progression only occurs in NASH: 27% develop

More information

Treatment and Management of NAFLD. Amanda Camp Wieland Fellow in Gastroenterology May 11, 2013

Treatment and Management of NAFLD. Amanda Camp Wieland Fellow in Gastroenterology May 11, 2013 Treatment and Management of NAFLD Amanda Camp Wieland Fellow in Gastroenterology May 11, 2013 Learning Objectives: Summarize the current epidemiology and natural history of Nonalcoholic Fatty Liver Disease

More information

HBV & HCV induced. Liver Cirrhosis Iradj Maleki MD Gut & Liver Research Center Mazandaran University of Medical Sciences

HBV & HCV induced. Liver Cirrhosis Iradj Maleki MD Gut & Liver Research Center Mazandaran University of Medical Sciences HBV & HCV induced Liver Cirrhosis Iradj Maleki MD Gut & Liver Research Center Mazandaran University of Medical Sciences Definition of Cirrhosis Final pathway for a wide variety of chronic liver diseases

More information

Luigi Muratori, MD, PhD Dipartimento di Scienze Mediche e Chirurgiche Policlinico Sant'Orsola via Massarenti, Bologna

Luigi Muratori, MD, PhD Dipartimento di Scienze Mediche e Chirurgiche Policlinico Sant'Orsola via Massarenti, Bologna Luigi Muratori, MD, PhD Dipartimento di Scienze Mediche e Chirurgiche Policlinico Sant'Orsola via Massarenti, 9 40138 Bologna Il sottoscritto dichiara di non aver avuto negli ultimi 12 mesi conflitto d

More information

Fatty Liver Disease. Donald Gardenier, DNP, FNP-BC, FAANP, FAAN Assistant Professor and Clinical Program Director

Fatty Liver Disease. Donald Gardenier, DNP, FNP-BC, FAANP, FAAN Assistant Professor and Clinical Program Director Fatty Liver Disease Donald Gardenier, DNP, FNP-BC, FAANP, FAAN Assistant Professor and Clinical Program Director Icahn School of Medicine at Mount Sinai New York, NY Conflict of Interest Disclosure Having

More information

HCV Treatment Failure

HCV Treatment Failure بسم االله الرحمن الرحيم HCV Treatment Failure Gamal Esmat PROF.OF HEPATOLOGY&TROPICAL MEDICINE CAIRO UNIVERSITY Director of Viral Hepatitis Treatment Centers (VHTCs( VHTCs) MOH-EGYPT www.gamalesmat.com

More information

City & Hackney CCG. Abnormal Liver Function Tests (LFTs) in Adults

City & Hackney CCG. Abnormal Liver Function Tests (LFTs) in Adults City & Hackney CCG Abnormal Liver Function Tests (LFTs) in Adults Interpreting abnormal liver function tests (LFTs) and trying to diagnose any underlying liver disease is a common scenario in Primary Care.

More information

PRIOR AUTHORIZATION PROTOCOL FOR HEPATITIS C TREATMENT

PRIOR AUTHORIZATION PROTOCOL FOR HEPATITIS C TREATMENT PRIOR AUTHORIZATION PROTOCOL FOR HEPATITIS C TREATMENT HARVONI (90mg ledipasvir/400mg sofosbuvir): tablet (PREFERRED AGENT) SOVALDI (sofosbuvir ): 400mg tablets (PREFERRED AGENT ) OLYSIO (simeprivir) PEG-INTRON

More information

Diagnosis and Management of Liver and Bile Duct Cancers. W. Thomas Purcell, MD University of Colorado Cancer Center April 26, 2014

Diagnosis and Management of Liver and Bile Duct Cancers. W. Thomas Purcell, MD University of Colorado Cancer Center April 26, 2014 Diagnosis and Management of Liver and Bile Duct Cancers W. Thomas Purcell, MD University of Colorado Cancer Center April 26, 2014 CONFLICT OF INTEREST DISCLOSURE 1) Off-label use of chemotherapy will be

More information

2.1 AST can be measured in heparin plasma or serum. 3 Summary of clinical applications and limitations of measurements

2.1 AST can be measured in heparin plasma or serum. 3 Summary of clinical applications and limitations of measurements Aspartate aminotransferase (serum, plasma) 1 Name and description of analyte 1.1 Name of analyte Aspartate aminotransferase (AST) 1.2 Alternative names Systematic name L aspartate:2 oxoglutarate aminotransferase

More information

Diagnosis of Acute HCV Infection

Diagnosis of Acute HCV Infection Hepatitis C Online PDF created August 23, 2016, 2:28 pm Diagnosis of Acute HCV Infection Module 1: Lesson 5: Contents: Screening and Diagnosis of Hepatitis C Infection Diagnosis of Acute HCV Infection

More information

BACKGROUND MEDIA INFORMATION Fast facts about liver disease

BACKGROUND MEDIA INFORMATION Fast facts about liver disease BACKGROUND MEDIA INFORMATION Fast facts about liver disease Liver, or hepatic, disease comprises a wide range of complex conditions that affect the liver. Liver diseases are extremely costly in terms of

More information

LAB 1 - Direct agglutination. Serology-the study of the in vitro reactions between antibody and antigen

LAB 1 - Direct agglutination. Serology-the study of the in vitro reactions between antibody and antigen LAB 1 - Direct agglutination Serology-the study of the in vitro reactions between antibody and antigen Serological reaction: - quantitative (weight/volume) - qualitative Agglutination - the aggregation

More information

Abnormal Liver Enzymes

Abnormal Liver Enzymes Abnormal Liver Enzymes Patrick Northup, MD, MHS Medical Director, Liver Transplantation Program Director, GI and Hepatology Fellowship University of Virginia liver@virginia.edu Case presentation 43 year

More information