NAFLD Diagnosis Algorithm
Two-step diagnostic strategy for NAFLD
1st step:
- Clinical biomarkers, scoring systems- FIB4, NAFLD fibrosis score, NAFIC, etc.
- Selection of patients who require further inspection of liver fibrosis.
2nd step:
- Ultrasound-based elastography, MR elastography
#NonAlcoholic #Fatty #Liver #Disease #NAFLD #Diagnosis #Algorithm #hepatology #NASH
Pathogenesis of Nonalcoholic Steatohepatitis. Various factors, including inflammation, hyperinsulinemia or insulin resistance, and altered lipid homeostasis, can induce metabolic stress, oxidative stress, and endoplasmic reticulum–related stress to develop in fatty hepatocytes (i.e., lipotoxicity). #Pathophysiology #GI #IM #NASH #NAFLD #NonAlcoholicSteatoHepatitis #NonAlcoholicFattyLiverDisease #NEJM
Non-Alcoholic Fatty Liver Disease (NAFLD) - Diagnosis Algorithm
Low Suspicion:
≤ 1 feature of MetS, No family history of cirrhosis
AND
FIB < 1.3 or NFS < -1.455, AST<20
Intermediate to High Suspicion:
≥ 2 of the following: obesity (BMI > 30 kg/m2, > 25 kg/m2 in Asians), age > family history of cirrhosis
OR
Any of the following: ≥ features of MetS, persistent AST > 20, FIB4 ≥ 1.3 or NFS ≥ -1.455
#NonAlcoholic #Fatty #Liver #Disease #NAFLD #Diagnosis #Algorithm #hepatology
Non-alcoholic fatty liver disease algorithm.
For those patients with NAFLD or liver disease of unknown aetiology, the next step is to determine the likelihood of liver fibrosis. Initial assessment includes calculation of a FIB4 or NAFLD fibrosis score with values <1.3 and ≤1.455, respectively, signifying a low risk of advanced fibrosis. Higher cut-off points, <2.0 and <0.12, should be used for patients aged over 65 years. Second-line tests that should be considered include serum markers such as ELF and imaging modalities such as ARFI elastography/FibroScan. For children, the text should be consulted for modification of recommendation. Cut-off points for ARFI vary according to manufacturer and thus should be tailored to the device used. ARFI, acoustic radiation force impulse; ELF, enhanced liver fibrosis; FIB-4, fibrosis-4; HCC, hepatocellular carcinoma; NAFLD, non-alcoholic fatty liver disease; NFS, NAFLD Fibrosis Score.
#NonAlcoholic #FattyLiver #Disease #NAFLD #algorithm #Referral #Management #Hepatology
Abnormal liver function tests algorithm.
This figure details the initial response to abnormal liver blood tests. Boxes in yellow indicate the initial evaluation of the clinical presentation. Patients with marked derangement of liver blood tests, synthetic failure and/or suspicious clinical symptoms/signs should be considered for urgent referral to secondary care (red box). For the remainder, a clinical history alongside evaluation of the pattern of liver blood test derangement will determine choice of pathway and is shown in the grey boxes. A grey box indicates all the tests that should be requested at that stage rather than a hierarchy within it. The presence of metabolic syndrome criteria should be sought to support a diagnosis of NAFLD. For children, the text should be consulted for modification of recommendation. Areas of diagnostic uncertainty are indicated in orange boxes and the decision for repeat testing or referral to secondary care will be influenced by the magnitude of enzyme elevation and clinical context. Green boxes indicate final/definitive outcomes for users of the pathway. *Abnormal USS may well include extrahepatic biliary obstruction due to malignancy, which should result in urgent referral. ALP, alkaline phosphatase; ALT, alanine aminotransferase; ARLD, alcohol-related liver disease; AST, aspartate aminotransferase; BMI, body mass index; FBC, full blood count; GGT, γ-glutamyltransferase; INR, international normalised ratio; LDH, lactate dehydrogenase; NAFLD, non-alcoholic fatty liver disease; T2DM, type 2 diabetes mellitus; USS, ultrasound scan.
#LFTs #Abnormal #Algorithm #Hepatology #Liver #Enzymes #Differential #Diagnosis
Clinical diagnosis of Alcoholic Hepatitis (AH)
• Onset of jaundice within prior 8 weeks
• Ongoing consumption of (female) or 60 (male) g alcohol/day for 26 months, with days of abstinence before the onset of jaundice
• AST >50, AST/ALT >1.5, and both values <400 IU/L
• Serum total bilirubin >3.0 mg/dL
Potential confounding factors
• Possible ischemic hepatitis (e.g., severe upper gastrointestinal bleed, hypotension, or cocaine use within 7 days) or metabolic liver disease (Wilson disease, alpha I antitrypsin deficiency)
• Possible drug-induced liver disease (suspect drug within 30 days of onset of jaundice)
• Uncertain alcohol use assessment (e.g., patient denies excessive alcohol use)
• Presence of atypical laboratory tests (e.g., AST or >400 IU/L, AST/ALT <1.5), ANA > 1:160 or SMA >1:80.
#diagnosis #Alcoholic #Hepatitis #AH #hepatology #criteria
Causes of Thrombocytopenia and Platelet Disorders - Differential Diagnosis and Workup
History:
- Prior platelet count, family history
- Medications
- Chronicity/severity
- History of bleeding (petechiae, ecchymoses, epistaxis, gingival bleeding, hematemesis, melena, heavy menstrual
- Recent procedures
- Infection exposure (l MD SOAP)
- Risks factor for HIV, HCV
- Alcohol use
- Dietary practices that could cause nutrient deficienies
Labs:
- Basic labs for decreased PLT count: CBC(.plateletcount), peripheral blood smear, HIV/HCV testing
- Lab for decreased PLT in selected cases: INR/PT, aPTT(liver disease, decrease vit K), H. pylori test (GI symptoms/endemic country), thyroid function test, ANA (e.g., SLE), anti-phospholipid antibodies, Quantitative IgA, IgG, IgM (CVID, WAS), (neurologic/psychiatric changes), high MCV anemia (vegan, gastric bypass), LFT (liver disease), HBsAg/anti-HBc (rituximab tx candidate)
- Bone marrow evaluation: not required in all patients with thrombocytopenia. However, it may be helpful in some patients if the cause of thrombocytopenia is unclear, or if a primary hematologic disorder is suspected. When do you do a BM aspiration/biopsy? Refractory ITP, unexplained pancytopenia, dysplasia on the smear
Dr. Jorge Cortés @Jcortesizaguirr
#Thrombocytopenia #Platelet #Disorders #Differential #Diagnosis #Causes #Workup #hematology
Recommended initial testing for patients being evaluated for glomerular disease
24-hour urine collection - Quantify proteinuria. Spot PC (protein/creatinine ratio) is not recommended for this purpose because it is unreliable in individual patients 166, 85, 87—891. Measuring albuminuria is useful in monitoring low-level glomerular proteinuria. However, once the total proteinuria exceeds 500 mg/day, albuminuria is about 60—80% of the total proteinuria. So, proteinuria provides the same information as albuminuria, and is less expensive
Serum albumin - Assess severity of the disruption of the GFB, and whether protein nutrition and hepatic albumin synthesis are adequate.
LDH - Assess for hemolysis, or damage to muscles or viscera.
Reticulocyte count/platelet count - Assess for increased or decreased red cell production. Assess for thrombotic microangiopathy.
SPEP+free light chains - Screen for monoclonal gammopathy (SPEP+ free light chains), or hypogammaglobulinemia, hypergammaglobulinemia (SPEP). Serum or urine for immunofixation is not recommended for routine screening because it is much more expensive than SPEP+free light chains, which are sensitive and specific for detection of monoclonal gammopathy [901.
C3, C4 - Test for disorders that activate the classical or alternative complement pathways.
Hepatitis B surface antigen, hepatitis C antibody, and HIV (if risk factors for HIV are present) - These infections are common causes of glomerular disease.
ANA - Screen for autoimmune disorders.
ANCA - Screen for ANCA-related vasculitis.
Rheumatoid factor - Screen for cryoglobulinemias (types 2 and 3), and certain autoimmune disorders
#glomerular #testing #workup #diagnosis #glomerulonephritis #nephrotic #nephritic #nephrology
