국가검진에서 발견된 간 검사이상의 접근법 진단, 감별진단, 치료 원칙 김진욱.

Presentation on theme: "국가검진에서 발견된 간 검사이상의 접근법 진단, 감별진단, 치료 원칙 김진욱."— Presentation transcript:

1 국가검진에서 발견된 간 검사이상의 접근법 진단, 감별진단, 치료 원칙 김진욱

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3 Liver enzyme의 pattern에 따른 감별진단

4 Biliary tract inflammation may mimick acute hepatitis
Giannini, E. G. et al. CMAJ 2005;172: Biliary tract inflammation may mimick acute hepatitis Old age Dominant symptom: epigastric / RUQ pain Alkaline phosphatase / GGT

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6 Serum aminotransferase levels in various liver diseases
In ischemic or toxic liver injury, AST levels usually peak before those of ALT because of the enzyme's peculiar intralobular distribution.27,28,29 Zone 3 of the acinus is more vulnerable to both hypoxic (hepatocytes are exposed to an already oxygen-poor milieu) and toxic (hepatocytes are richer in microsomal enzymes) damage. Giannini, E. G. et al. CMAJ 2005;172: Copyright ©2005 CMA Media Inc. or its licensors

7 But, not mutually exclusive
나이에 따라 급성 간염의 흔한 원인이 다르다 30대 이하 바이러스 간염 자가면역 간염 (여>남) 40대 이상 Toxic / drug / alcohol 담도계 질환 But, not mutually exclusive

8 enterically transmitted
Acute Viral Hepatitis enterically transmitted blood-borne Type HAV HEV HBV/HDV HCV Course Self-limited Can be chronic Risk household contam.food bivalve mollusk sporadic(endemic) contam.water blood sexual penetration vertical Dx Anti-HAV( IgM) Anti-HEV (IgM) HBsAg Anti-HBc (IgM) HCV RNA PCR

9 성남지역급성바이러스간염증례의 원인별 분포 - 246 cases, 2006.9-2007.8 -
U B C E A+E A

10 급성간염의 감별에 도움이 되는 병력 여행력: HAV, HEV, Dengue, malaria 멧돼지, 소 간/천엽 생식: HEV
현재 복용중인 약물: NSAID, statin, PPI 각종 건강보조..: 백선(봉삼), 나무껍질, Sexual contact: HBV, HCV Previous GI sx: 담석증 Hypotensive episode, acute heart failure

11 Change of aminotransferase and bilirubin levels in a patient with acute ischemic hepatitis (green area, yellow area respectively) and acute viral hepatitis (blue area, orange area respectively)

12 급성 바이러스간염의 증상 Asymptomatic Nonspecific Jaundice, RUQ discomfort
malaise anorexia nausea vomiting flu-like respiratory sx-HA myalgia Jaundice, RUQ discomfort Acute liver failure Encephalopathy Coagulopathy Ascites Multiple organ failure Cholestatic hepatitis HAV / prolonged jaundice, itching for months Relapsing hepatitis HAV / sx, liver test abnormalities recurs age Encephalopathy: personality change, reversal of sleep pattern, lethargy, drowsiness, coma

13 Clinical course of hepatitis A
HBV&HDV coinfection: fewer than 2% of cases were reported to progress to chronicity

14 Clinical course of hepatitis B

15 Serologic response to HBV
HBsAg HBV infection? HBV immune? Previous exposure? AVH-B? CH-B activity? HBsAb HBcAb HBsAg + HBcAb IgM HBeAg + HBV DNA

16 Clinical course of hepatitis C

17 Case

18 38/F

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23 Primary biliary cholangitis (PBC)
previously known as Primary Biliary Cirrhosis 0.09 to 4.02/10,000 Ursodeoxycholic acid is the only treatment available

24 Dx of PBC 1. Persistent increase (>6 months) of serum levels of alkaline phos-phatase (ALP) in patients with normal results at ultrasoundexamination of the biliary tract 2. Positivity of AMA (title >1:40 at IF measurement) or anti- Sp100and anti gp210 subtypes of anti nuclear antibodies (ANA) 3. Histologic evidence of nonsuppurative obstructive cholangitisinvolving interlobular bile ducts.

25 62/F, abnormal LFT

26 62/F, abnormal LFT

27 52/M

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33 51 F

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38 Pd 30mg +Azathioprine 50mg since 9-19-2012

39 41여

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47 19 / F CC: nausea Previously healthy 3DA fever, sore throat, neck LN
4hrs ago fever, vomiting: visited ER Respiratory sx (-), nausea (+) 123/72, HR 121/min, BT38.9’C

48 Bilateral tender lymphadenopathy, neck
Pharyngeal ulcer+ injection+

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51 31 / M, icteric sclera

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54 Gilbert syndrome AD with variable penetrance M > F
UDP-glucuronosyltransferase ↓ bilirubin < 5 mg/dL (usu. 2-3) fasting, fat free diet, infection normal histology DDX: hemolysis, indinavir, atazanavir

55 68/M, abnormal LFT

56 68/M, abnormal LFT

57 68/M, abnormal LFT

58 68/M, abnormal LFT

59 68/M, abnormal LFT

60 요약 나이, 주 증상, risk factor가 가장 중요 음주력 약물 복용력
AST / ALT 비, ALT / Alk phos비 가장 흔한 이상은 지방간