Key Consultations in Hepatology

Contents

Preface xi

Paul Martin

TheAsymptomatic Outpatient with Abnormal Liver Function Tests 167

Michael Krier and Aijaz Ahmed

Traditionally, the constellation of biochemistry tests including liver en-zymes, total bilirubin, and hepatic synthetic measures (prothrombin time(PT) and serum albumin level) are referred to as liver function tests (LFTs).Abnormal LFTs can be encountered during primary health care visits, rou-tine blood donation, and insurance screening. A reported 1% to 4% ofasymptomatic patients exhibit abnormal LFTs, leading to a sizeable numberof annual consultations to a gastroenterology and/or hepatology practice. Acost-effective and systematic approach is essential to the interpretation ofabnormal LFTs. A review of pattern of abnormal LFTs, detailed medical his-tory, and a comprehensive physical examination help establish a foundationfor further individualized testing. Further investigation often involves bio-chemical testing for disease-specific markers, radiographic imaging, andeven consideration of a liver biopsy. In the following account, markers of he-patic injury are reviewed followed by a discussion on an approach to variouspatterns of abnormal LFTs in an asymptomatic patient.

The Hospitalized Patient with Abnormal Liver Function Tests 179

Christopher B. O’Brien

Evaluation of abnormal liver function tests (LFTs) in the hospitalized pa-tient is typically more urgent than the outpatient setting. This process isbest organized into four steps. The first step is to determine whetherthe abnormal LFTs are associated with the illness resulting in the admis-sion to the hospital or preceded the present illness. The second is to de-termine the etiology of the underlying liver disease. The third step is toevaluate the severity of the liver dysfunction and determine if acute liverfailure (ALF) or acute decompensation of chronic liver failure is present.The final step is to look for the presence of associated complications—either those of ALF or chronic liver failure as appropriate.

Approach to a Liver Mass 193

Oren Shaked and K. Rajender Reddy

Incidentally discovered liver masses are becoming more common with theincreasing application and power of imaging techniques for the evaluationof abdominal conditions. Although such masses are often benign, conclu-sive diagnoses must be established in order to provide appropriate patientcare. Various imaging modalities can be utilized to accurately diagnosesuch masses without resort to more invasive diagnostic measures.

Contentsviii

Surgery in the Patient with Liver Disease 211

Jacqueline G. O’Leary, Patrick S. Yachimski, and Lawrence S. Friedman

The advent of liver transplantation has greatly improved the long-term sur-vival of patients with decompensated cirrhosis, and surgery is now per-formed more frequently in patients with advanced liver disease. Theestimation of perioperative mortality is limited by the retrospective natureof and biased patient selection in the available clinical studies. The overallexperience is that, in patients with cirrhosis, use of the Child classificationand Model for End-Stage Liver Disease (MELD) score provides a reason-ably precise estimation of perioperative mortality. Careful preoperativepreparation and monitoring to detect complications early in the postoper-ative course are essential to improve outcomes.

Modern Diagnosis and Management of Hepatocellular Carcinoma 233

Jorge A. Marrero and Theodore Welling

The incidence of hepatocellular carcinoma (HCC) is rising, and the numberof patients with HCC is expected to more than double over the next 1 to 2decades. HCC meets the criteria for establishment of a surveillance pro-gram. Patients with cirrhosis, regardless of the cause, are at the highestrisk for developing HCC and this is the population in which surveillanceshould be performed. (Alpha-fetoprotein and hepatic ultrasonographyare the currently recommended surveillance tests. If a surveillance test isabnormal, there is a need for a recall test for diagnostic evaluation ofHCC. Triple-phase imaging is recommended for evaluation at recall, withMRI being more sensitive and specific. Novel genetic markers can improvethe histologic diagnosis of early HCC. The Barcelona staging classificationis the best system for determining the prognosis of patients and it is linkedto an evidence-based treatment algorithm. Resection, transplantation,and percutaneous ablation are considered curative interventions and arecurrently applied to about 30% of all patients with HCC.

Nonalcoholic Fatty Liver Disease: A Practical Approach to Evaluationand Management 249

Nila Rafiq and Zobair M. Younossi

Non-alcoholic fatty liver disease (NAFLD) has become one of the mostcommon forms of chronic liver disease in the Western world. The rise inNAFLD is thought to be associated with the prevalence of metabolic syn-drome. NASH is a subtype of NAFLD that may progress to cirrhosis andend stage liver disease. Although there are no approved treatment regi-mens for NAFLD or NASH, a number of different interventions are beingtested. Meanwhile, most experts advocate that components of metabolicsyndrome should be effectively treated.

Management of Alcoholic Liver Disease 267

Michael R. Lucey

Understanding alcohol addiction and abstinence is key to treating alco-holic liver disease, since abstinence leads to improvement in all forms ofalcoholic liver damage. Although pharmacotherapy for alcoholism, usingagents such as naltrexone, acamprosate, topiramate, and baclofen, isan exciting field, few studies have included patients with liver disease or

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cirrhosis. To treat alcoholic liver injury, corticosteroids have become thestandard of care in patients with severe alcoholic hepatitis. In contrast,the role of pharmacotherapy to treat alcoholic fibrosis is unclear, with fail-ure to observe a benefit in randomized, placebo-controlled clinical trials ofcolchicine, S-adenosylmethionine (SAMe), or phosphatidylcholine. Livertransplantation remains an option in selected patients with life-threateningalcoholic liver disease.

Drug-Induced Hepatotoxicity or Drug-Induced Liver Injury 277

Aaron J. Pugh, Ashutosh J. Barve, Keith Falkner, Mihir Patel,and Craig J. McClain

Drug-induced hepatotoxicity is underreported and underestimated in theUnited States. It is an important cause of acute liver failure. Common classesof drugs causing drug-induced hepatotoxicity include antibiotics, lipid low-ering agents, oral hypoglycemics, psychotropics, antiretrovirals, acetamin-ophen, and complementary and alternative medications. Hepatotoxic drugsoften have a signature or pattern of liver injury including patterns of liver testabnormalities, latency of symptom onset, presence or absence of immunehypersensitivity, and the course of the reaction after drug withdrawal.

Management of Autoimmune and Cholestatic Liver Disorders 295

Karen L. Krok and Santiago J. Munoz

The management of autoimmune and cholestatic liver disorders is a chal-lenging area of hepatology. Autoimmune and cholestatic liver diseasesrepresent a comparatively small proportion of hepatobiliary disorders,yet their appropriate management is of critical importance for patient sur-vival. In this article, management strategies are discussed, including theindications and expectations of pharmacologic therapy, endoscopic ap-proaches, and the role of liver transplantation.

HepatitisVaccination and Prophylaxis 317

Carolyn T. Nguyen and Tram T. Tran

The three most commonly identified causes of viral hepatitis in the UnitedStates are hepatitis A virus (HAV), hepatitis B virus (HBV), and hepatitis Cvirus (HCV). Hundreds of millions of people worldwide are infected bythese viruses; many experience illness as a result. This article discussescurrent recommendations for vaccination and other forms of prophylaxisaimed at minimizing the clinical effects of these viruses.

Care of the Cirrhotic Patient 331

Priya Grewal and Paul Martin

Timely surveillance for varices and hepatocellular carcinoma, prophylaxisagainst spontaneous bacterial peritonitis (SBP) improve survival in patientsawaiting transplantation. Early diagnosis of minimal or overt hepaticencephalopathy can delay life threatening complications, reduce needfor hospitalization, and potentially improve survival pending livertransplantation.

Index 341