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Jandice, Case 1. 55 yrs male, Hepatocellular pattern: ALT/AST elevated…
Jandice
History taking
(mainly focus on drug exposure)
Percussion
1.Tympany or Dullness
2.Liver scan(8~12cm)
Nipple to 10th rib
Palpation
1.Edge of the liver
2.Rebound tenderness
Auscultation
1.Bowel round
2.Bruit
Inspection
1.Asymmetry
2.Scar
3.Location
4.Vein engorgement
Isolated bilirubin上升
Indirect hyperbilirubinemia
(direct<15%)
Impaired uptake by liver
Drugs
Rifampin
Probenecid
Inherited disease
Criger-Najjar typeI/II
Gilbert’s syndrome
Overproduction of bilirubin
Hemolytic disorder
Infective erythropoiesis
Increased bilirubin production
Direct hyperbilirubinemia
(direct>15%)
D-Bil轉運 排泌障礙（Hepatic)
Dubin-Johnson syndrome
Indirect/direct bilirubin
排泌障礙
Rotor syndrome
Bilirubin and liver test 數值上升
Cholestatic pattern:
Alkaline phosphatase out of proportion ALT/AST
膽道問題
Ultrasound
Dilated
肝外膽管阻塞
Malignant
Cholagiocarcinoma
Pathophysiology
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Clinical symptom
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Evaluation
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Risk factor
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Differential diagnosis
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Benign
Primary Sclerosing Cholangitis
Choledocholithiasis
Pathophysiology
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Clinical symptoms
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Risk factor
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Evaluation
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Differential Diagnosis
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Gallstones differentiation
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gallstone pancreatitis
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Case 2
Chronic pancreatitis
AIDS related
not dilated
肝內膽管阻塞
Primary sclerosing
cholangitis
risk factor
45 歲以下(男 : 女 = 3 ： 2)
與感染、中毒和自身免疫有關
symptom
有漸進性加重的乏力
瘙癢和黃疸
右上腹痛、膽管炎
膽管影像
串珠狀，不規則
AMA（-）
肝外膽管病變最明顯、管腔細、無膽石
lab test
ALP、γ-GT 等明顯上升
GOT 與 GPT 輕度上升
銅藍蛋白 (Ceruloplasmin，CER)上升
serum Albumin 下降
Primary biliary cholangitis
risk factor
40~60歲的中年婦女(男:女是1：9)
北歐地區
自體免疫性疾病
抗粒線體自身抗體(Anti-Mitochondrial Antibody，AMA)及IgM皆升高
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symptom
早期:皮膚、鞏膜黃染、皮膚搔癢和脫屑
後期逐漸出現肝、脾腫大，但表面尚光滑，無壓痛
膽管影像
串珠狀，不規則
AMA（＋）
肝外膽管正常
lab test
ALP、γ-GT 等明顯上升
GOT 與 GPT 正常或輕中度上升
凝血酶原時間上升
尿膽紅素 (+)
Case 1.
55 yrs male
Chief complaint
腹圍變大
雙側下肢水腫
尿少 紅茶色
PE
語無倫次
鞏膜發黃
腹部有shift dullness
下肢pitting edema
Past history
長期酗酒
每天喝超過80g的酒精
Lab
Total bil. 5.4mg/dL
Direct bil. 40 mg/dL
AST 290 U/L
ALT 129 U/L
ALP 95 U/L
albumin 2.5 g/dL
GGT 825 U/L
INR 2.2(normal:0.8－1.2)
血氨100 umol/L(normal:9-35 μmol/L)
Hepatocellular pattern:
ALT/AST elevated out of proportion to alkaline phosphatase
肝細胞大面積壞死
Autoimmune hepatitis
Type1:
lab:ANA,smooth muscle antibody
較好治療，不易復發
Diagnosis
hypergammaglonulinemia
antibody:ANA,SMA,anti-LKM1 titers
Complication
Graves’ disease
Ulcerative colitis
Autoimmune thyroiditis
Type2:
lab:liver-kidney microsomes 1 antibody
liver cytosol 1 antibody
較嚴重
Environmental toxicity
Metabolic hepatitis
Wilson’s disease
ATP7B gene mutation
Abnormal copper metabolism
Clinical presentation
men:women=2:1
0~10y/o:hepatitis,hemolysis
10~y/o:neuron
Kayser-Fleischner rings
Diagnosis
Urinary copper
serum ceruloplasmin
Kayser-Fleischner rings
Hemochromatosis(Iron overload)
HFE gene mutation
symptom
Cirrhosis
Diabetes
increased pigmentation
Diagnosis
genetic:
C282Y/C282Y
C282Y/H63D
Blood:
transferrin saturation>50%(normal<45%) serum ferritin level>1000ng/ml
(normal<150)
Viral hepatitis
Viral A
Incubation period
30 (15-45)days
Jaundice by age group:
<6 yrs, <10%
6-14 yrs, 40%-50%
14 yrs, 70%-80%
Genome
ssRNA
Transmission
Fecal-oral
Chronic disease
Never
Diagnosis
IgM Anti-HAV
if positive:Acute hepatitis A
Viral B
Incubation period
60 (50-180)days
Jaundice by age group:
<5 yrs, <10%
5 yrs, 30%-50%
Genome
dsDNA
Transmission
Parenteral
Chronic disease
<5 yrs, 30%-90% >5 yrs, 2%-10%
Diagnosis
HBsAg
positive
negative
IgM Anti-HBc
positive
negative
Oncogenic
Viral C
Incubation period
50 (15-160)days
Jaundice:
20-30%
Genome
ssRNA
Transmission
Parenteral
Chronic disease
80%
Diagnosis
Anti-HCV
if positive:Acute hepatitis C
Oncogenic
Viral D
Genome
ssRNA
Transmission
Parenteral
Chronic disease
often
Diagnosis
Detection of serum HDV RNA
Detection of anti-HDV antibody
Detection of serum HDAg
HDAg and HDV RNA can be detected in liver tissues
Viral E
Incubation period
40 (15-60)days
Genome
ssRNA
Transmission
Fecal-oral
Chronic disease
Never
Diagnosis
HEV RNA assay(stool and serum)
IgM anti-HEV
IgG anti-HEV
vast majority of patients are asymptomatic or mildly symptomatic
if symptomatic
jaundice
anorexia
fever
drug toxic
普拿疼（acetaminophen)
結核病藥INH
Anesthesia agents
Anti-convulsants
Alcoholic hepatitis
risk factor
male:>40g ethanol per day
female:>20g ethanol per day
Observed
CAGE questions score >2
Symptom
jaundice that developed within three months prior to presentation
Observed
anorexia
fever
tender hepatomegaly
Right upper-quadrant abdominal pain
Abdominal distension due to ascites
Observed
Proximal muscle weakness due to muscle wasting
Hepatic Encephalopathy
認知功能受損
（按嚴重程度）
Grade2:疲倦、中等confusion
Grade3:明顯confusion、語無倫次
Observed
Grade4:昏迷、對疼痛無反應
Grade1:行為改變、輕微confusion
Diagnosis
PE
黃疸
鞏膜發黃
Observed
蜘蛛痣
腹水
肝脾腫大
杵狀指
Capital medusae
抽血檢查
Total Bilirubin 升高
Observed
Direct bil.升高
Observed
ALT/AST升高(typically less than 300 int. unit/L, rarely higher than 500 int. unit/L)
AST:ALT ratio ≥2
ALP升高
Observed
Albumin下降
Observed
elevated gamma-glutamyl transferase (GGT)
elevated international normalized ratio (INR)
血氨上升
影像學檢查
肝臟表面不規則、出現結節變化
Histologic findings
micro- or macrovesicular Steatosis
Mallory-Denk bodies
eosinophilic accumulations of intracellular material
neutrophilic infiltration
Cholestasis
Bile duct proliferation
Chronic hepatitis B
Acute hepatitis B
Acute hepatitis B (HBsAg
below detection threshold)
Observed
Observed
Observed
Observed