41 Liver disorders     [Example]

Examination
CRP, ALAT, ASAT, gGT, ferritin, iron, transferrin (saturation), bilirubin, hemoglobin, MCV, erythrocytes, leukocytes, thrombocytes, lipids, uric acid. Potentially hepatitis B/C serology, Epstein-Barr virus (EBV)/cytomegalovirus (CMV)/toxoplasmosis-serology


Rationale
When ALAT is >1.5 times the upper limit of the reference value (Limdi and Hyde, 2003), consider chronic viral hepatitis (hepatitis B/C) after risk factor assessment. Risk factors: countries with endemic hepatitis, risk full lifestyle, drug addiction. Also when no complaints are mentioned (Dutch guideline for GPs (M22): NHG-Standard Viral hepatitis and other liver disorders, 2007).

  • NASH/steatosis
  • Alcohol
  • Hemochromatosis
  • Cholestasis
  • Medication (e.g. statin)
  • Liver disorders are related to NASH (non-alcoholic steatohepatitis), steatosis, alcohol abuse


Remarks

  • ALAT elevated. Is the patient obese? Obesity causes steatosis, a frequent cause of liver enzyme elevation. Triglycerides and ferritin levels are usually elevated with steatosis. Steatosis can be detected by a liver echography.
  • Cave chronic viral hepatitis (see NHG-Standard M22) or other liver disorders such as steatosis, alcohol, mononucleosis infectiosa, or resulting from use of drugs. Risk factors (relationship with endemic area, risk full contacts, drugs, contaminated medical procedures)? Consider virus serology hepatitis B/C.
  • Vitamin B12 level correlates with liver damage when intoxicated (e.g. from alcohol). When vitamin B12 >0.9 ng/ml, there are possible clinical indications of liver damage.
  • Elevated liver enzymes, including alkaline phosphatase and bilirubin. This is consistent with biliary tract obstruction.
  • Liver enzymes elevated. Non-alcoholic steatosis (fatty liver) often appears in cases of obesity and metabolic syndrome as indicated by an elevated gGT/ALAT, triglycerides, uric acid and ferritin and a decreased HDL cholesterol level. Alcohol abuse can produce the same disorders (sometimes with increased MCV and ASAT>ALAT).
  • Cave infection (mononucleosis infectiosa, cytomegalovirus (CMV), toxoplasmosis), even when no atypical lymphocytes are observed. Is serology requested?
     
Example
43 year old male; added: lipids, uric acid, ferritin