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home - Liver - Autoimmune Conditions - Autoimmune Hepatitis Diagnosis Written by Dr Sebastian Zeki
Knowledge


Recognises and appropriately investigates patients with auto-immune
liver diseases

Aware of management and complications of autoimmune liver
disease including extra-hepatic manifestations and associations
including malignant complications in PSC

Skills
Appreciates and understands that this range of liver disease is
frequently under-diagnosed and may have been inappropriately
managed

Selects appropriate immunomodulatory therapy has awareness of
side effects and may well require specialist care

Behaviours
Responds urgently to the management challenge of these severe and
often acute diseases and involves more specialist services where
required

Autoimmune Hepatitis Diagnosis

AIH-PSC Overlap25% of patients with AIH have PSC.The complex is of AIH on serology but PSC on cholangio- Written by Dr Sebastian Zeki 10% PBC may have AIH variant-can develop before, during or after diagnosisTypesHistology of autoimmune hepatitis, serology of PBC : Clinical course as per type 1 AIHHistology of PBC but no AMA, and generally with antinuclear antibodies (ANA) +/-smooth muscle antibodies (SMA). (AKA immune cholangiopathy, autoimmune cholangiopathy, immune cholangitis, and autoimmune cholangitis, AMA-negative PBC.Subtypes1. AMA +ve or AMA -ve patients with ANA-PBC-related antibodies 2. AMA -ve patients with non-PBC-related ANAs 3.Patients with autoimmune hepatitis-related antibodies with serum PBC markersClinical Implications:AIH superimposed upon PBC more likely to develop esophageal varices, GI bleeding, ascites, and liver failure compared with more classical PBC Reasons to suspect AIH PSC overlapPruritus.Chronic ulcerative colitis (in16 % with AIH).Bile duct abnormalities on histology (eg. portal edema, cholestasis, and fibrous or obliterative cholangitis).Cholestatic laboratory changes (ALP>2xULN).The patient has no response to corticosteroid therapy.An abnormal cholangiogram (in up to 42 % of AIH and UC). High levels of IgG, circulating ANA or SMA (titer >1:40), and moderate to severe interface hepatitis on liver biopsy Evolution from AIH to PSC has also been described.Compared to PSC, AIH-PSC younger at presentation (mean age 21 v 32) had higher aminotransferases, serum Ig’s and prevalence of autoantibodies. Diagnosis of Autoimmune Hepatitis ALKM-1 occur +/-ALC-1 (LC1) antibodies or rarely ANA. ALC-1 antibodies can occur aloneAnti SLA/LP are common Treat as ryptogenic chronic hepatitis or cryptogenic cirrhosis. A therapeutic response to antiinflammatory therapy may be the only indication that autoimmune hepatitis is the underlying disease in these patients. Most common Type 1 diabetesAutoimmune thyroid disease,Vitiligo.Also assoc with a syndrome of vitiligo, nail dystrophy, and alopecia, and with autoimmune polyglandular syndrome type I. Most commonThyroiditisGraves' diseaseUlcerative colitis (16%) Rheumatoid arthritis.Also: uveitis, celiac disease, pernicious anemia, Sjögren's syndrome, mixed connective tissue disease, Weber-Christian panniculitis and CREST syndrome. Extrahepatic manifestations of autoimmune hepatitisBoth types 10 % have coeliac diseaseExtrahepatic manifestations assoc with HLA-DR4HLA alleles that seem to confer susceptibility to autoimmune hepatitis is associated with resistance to ulcerative colitis. Rash/ arthralgia/ anorexiaAutoimmune association in 30% 80% female >50 20-30 Ab -ve AIH Autoantibodies Organ- specific Ab’s Possible CommonAutoantigen Unknown CYP2D6HLA B8, DR3, DR4 DR7,B14,DR3,C4A-Q0Age Adult ChildFulminant Onset Possible PossibleLow IgA No PossibleProg to cirrhosis 36% 82%Steroid response Yes YesExtrahepatic anti SLA/LP LKM1Asiaglycoprotein recepLiver cytosol 1 Smooth muscleNucleusActinpANCA 3 2 1 Diagnostic Criteria-ALT is raised- reliably reflects hepatic inflammation.-IgG is 1.5x normal.-SMA, ANA or LKM1 is >1:80.-Histology shows interface hepatitis with or without lobular hepatitis or bridging necrosis in absence of other problems.If +ve histol, negative ab’s send off pANCA and SLA/LP. Anti SLA/LP (IgG1 subtype) - 10%Useful to dx when ANA or ASMA. Anti-dsDNA +vity assoc with HLA DR4- identifies steroid non-responders PANCA common Asialoglycoprotein in 85% of pre-tx active disease AIH-PBC Overlap

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