Transcript Διαφάνεια 1 - 8th Larissa International Congress of Internal Medicine

AN EPIDEMIOLOGICAL SURVEY : 103 PATIENTS WITH ELEVATED
TRANSAMINASES IN A RANDOM CHECK
I.Staikos, K.Krapis, N.Aggelis, K.Karamitsos
GENERAL HOSPITAL OF LARISSA,
INTERNAL MEDICINE DEPARTMENT
Common causes of elevated transaminases
The elevated transaminases (AST/ALT) is a common laboratory finding and its
clinical impact often concerns the doctor of the primary, secondary even
tertiary medical care.
Their elevation implies liver cell damage and is followed by necrosis.
Alcohol abuse
Hepatitis B (chronic)
Hepatitis C (chronic)
ALT seems to be the most sensitive enzyme of liver damage, as it is most
found in liver, whereas AST is found in muscles, heart, kidneys, lungs,
pancreas, red blood and white blood cells, brain.
Steatosis/steatohepatitis
At about 5% of the general population have elevated values of transaminases
ALT/AST without any symptomatology.
Less common causes
Medications/toxins/dietary supplements
Autoimmune hepatitis
Hyperthyroidism
Exercise
Hemochromatosis (primary or secondary)
Alpha1-antitrypsin deficiency
Wilson’s disease
Rare causes
Celiac disease
Addison's Disease
Myopathy
Cuadrado A, Crespo J. Hypertransaminasemia in patients with negative viral markers. Rev Esp Enferm Dig
2004; 96: 484-500. table 1
Macro-AST
Γ.Ν.Νταλέκος, Χ.Λιάσκος, Κ.Ζάχου, Ε.Μακρή και Μ.Βενιζέλος. Αντιμετώπιση
ασυμπτωματικών ασθενών με διαταραχές των ηπατικών ενζύμων, ΚΕΕΛ
For epidemiological reasons there has been a record of patients who
have developed elevated values of transaminases in random check at
the outpatient clinic of the Internal Medicine Department. Patients who
were referred to the outpatient clinic from smaller public health
services and private doctors’ offices for the probe of this finding were
also included in this sample.
The final sample is composed by 103 patients in total, from whom 53
were male and 50 female.
Their age range is between 22 and 76 years old.
Patients’ sample
Patients who were included in the survey belonged to both sexes and
to the whole range of ages.
As inclusion criteria have been used the presence of elevated values
of transaminases (AST and/or ALT>40) in at least two measurements
in time between 7-14 days.
The exclusion criteria are a) the presence of diagnosed liver disease,
b) the presence of known systematic disease with possible liver
contribution, c) clinical symptomatology which has to do with liver and
biliary disease.
All the patients included come from the wide area of Thessaly,
although there were not used criteria for exclusion concerning the
origin or the domicile.
67 patients were receiving a sort of medication.
34 patients presented another disorder of the liver biochemistry
except for transaninases, mostly GGT.
92 patients had elevated values <5 times more than the normal, while
11 patients had values five or more times elevated than the ones
which are considered to be normal.
disease/age 20-40
%
40-60
60-80
total
HBV
13
6
3
22
21
HCV
9
3
4
16
15
Alcoholic
3
6
9
18
17
Drug induced
0
4
7
11
10
NAFLD
2
4
3
9
9
CMV
0
1
0
1
1
Gallstones
0
1
0
1
1
Wilson
1
0
0
1
1
Autoimmune
hepatitis
0
2
0
2
2
No diagnosis
6
11
5
24
23
From the results, a not predictable raise of the percentages of viral
hepatitis has been occurred (38 cases- 37%), mainly concerning the
young and middle ages. Furthermore, there was a slight ascendance
of HBV over HCV (21% over 15%).
From the patients with viral hepatitis (HBV and HBC) 55% had
AST/ALT ratio > 0,8, whereas in 45% it was < 0,8.
In addition, a great impact was developed by the alcoholic disease
(17%), where the main part of the patients was middle and over aged,
with a clear distribution of those who were over 60 years old. These
patients developed AST/ALT ratio > 2 in the percentage of 78%.
The drug induced hepatitis followed with 10%. Specifically, seven
cases were attributed to statins, three to NSAIDs and one to fibrates.
The NAFLD, whose percentages, in general acknowledgement, are
constantly rising, was found surprisingly low in this specific sample
with a percentage of only 9% (nine cases). From those, six were
suffering from Diabetes Melitus and two were obese.
In this particular group the AST/ALT ratio was < 1 in seven out of the
nine cases (77%)
The no diagnosis/other group consists of cases where laboratory
finding was no long present in later examinations and it resolved by
itself.
Two cases of autoimmune hepatitis and one of Wilson's disease are
worth being mentioned.
The recorded raise of viral hepatitis, probably a result of the financial
crisis and the decline of the subsistence level, sounds the alarm for
the doctor, as an early diagnosis can lead to an effective treatment,
whereas the delay of the intervention can be disastrous for the
patient, even for public health.
Moreover, it is clear that the alcoholic disease of liver is a great
concern for health care. From the 18 patients with alcoholic liver
disease, three of them had clues of early cirrhosis and only one end
stage liver disease, showing that the early enough intervention can
have spectacular results.
Finally, three cases needed hospitalisation and probe in the
Hepatology Department of Univerity of Thessaly, fact that shows the
importance of the particular structure.
REFERENCES
1. Cuadrado A, Crespo J. Hypertransaminasemia in patients with negative viral markers. Rev Esp Enferm Dig 2004; 96: 484-500.
2. Dufour DR, Lott JA, Nolte FS, et al. Diagnosis and monitoring of hepatic injury. II. Recommendations for use of laboratory tests in screening, diagnosis, and
monitoring. Clin Chem 2000; 46: 2050-68
3. Kundrotas LW, Clement DJ. Serum alanine aminotransferase (ALT) elevation in asymptomatic US Air Force basic trainee blood donors. Dig Dis Sci.
1993;38:2145–50.
4. Lawrence S Friedman, Sanjiv Chopra, MD, Anne C Travis, Approach to the patient with abnormal liver biochemical and function tests, UpToDate 21 Jan 2015
5. Pratt DS, Kaplan MM. Evaluation of abnormal liver-enzyme results in asymptomatic patientsN Engl J Med 2000; 342:1267
6. Γ.Ν.Νταλέκος, Χ.Λιάσκος, Κ.Ζάχου, Ε.Μακρή και Μ.Βενιζέλος. Αντιμετώπιση ασυμπτωματικών ασθενών με διαταραχές των ηπατικών ενζύμων, ΚΕΕΛ