肝機能障害のおおまかな分類

AST・ALTの値からみた場合の疾患の分布
出典
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1: Liver enzyme alteration: a guide for clinicians.
著者: Edoardo G Giannini, Roberto Testa, Vincenzo Savarino
雑誌名: CMAJ. 2005 Feb 1;172(3):367-79. doi: 10.1503/cmaj.1040752.
Abstract/Text: Isolated alterations of biochemical markers of liver damage in a seemingly healthy patient can present a challenge for the clinician. In this review we provide a guide to interpreting alterations to liver enzyme levels. The functional anatomy of the liver and pathophysiology of liver enzyme alteration are briefly reviewed. Using a schematic approach that classifies enzyme alterations as predominantly hepatocellular or predominantly cholestatic, we review abnormal enzymatic activity within the 2 subgroups, the most common causes of enzyme alteration and suggested initial investigations.
CMAJ. 2005 Feb 1;172(3):367-79. doi: 10.1503/cmaj.1040752.

原因不明の肝機能障害を肝生検で診断した354例の結果

66％はNASH、脂肪肝
出典
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1: Findings on liver biopsy to investigate abnormal liver function tests in the absence of diagnostic serology.
著者: M M Skelly, P D James, S D Ryder
雑誌名: J Hepatol. 2001 Aug;35(2):195-9.
Abstract/Text: BACKGROUND/AIMS: The significance of abnormal liver function tests in the absence of diagnostic serology is unclear. The aim of this study was to report liver biopsy findings in a large group of patients with unexplained abnormal liver biochemistry.
METHODS: Histological findings were examined in 354 patients who underwent liver biopsy to investigate abnormal liver function tests.
RESULTS: Six percent of patients had a normal liver biopsy while 26% were found to have some degree of fibrosis and 6% were cirrhotic. Thirty four and 32% of biopsies suggested non-alcoholic steatohepatits or fatty liver respectively. Other diagnoses included cryptogenic hepatitis, drug toxicity, primary and secondary biliary cirrhosis, autoimmune hepatits, alcohol-related liver disease, primary sclerosing cholangitis, haemochromatosis, amyloid and glycogen storage disease. Patient management was directly altered in 18% of patients due to liver biopsy findings and three families were entered into screening programmes for inheritable liver disease.
CONCLUSIONS: The finding of abnormal liver function tests in the absence of diagnostic serology may indicate significant liver disease. Liver biopsy yields a range of liver diseases of diverse nature and extent. Liver diseases may be uncovered for which specific treatment is indicated.
J Hepatol. 2001 Aug;35(2):195-9.

脂肪肝の超音波検査画像

LK　contrast（肝腎コントラスト）　陽性
出典
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1: 著者提供

肝機能障害の診断フローチャート

肝機能障害（AST・ALT）で異常があった場合に、どのように検査を進めていくかを示す。
鑑別診断を考えて、次のステップに進んでいく。

血液検査による肝機能障害の病態推定

肝機能障害を来す原因により、肝機能障害の検査結果に一定のパターンがある。
しかし、実臨床で完全に一致するわけではないため、これらの検査結果のみで判断することは推奨しない。
出典
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1: 著者提供

診断のきっかけとなる病歴や検査項目

出典
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1: Mildly elevated liver transaminase levels in the asymptomatic patient.
著者: Paul T Giboney
雑誌名: Am Fam Physician. 2005 Mar 15;71(6):1105-10.
Abstract/Text: Mild elevations in liver chemistry tests such as alanine transaminase and aspartate transaminase can reveal serious underlying conditions or have transient and benign etiologies. Potential causes of liver transaminase elevations include viral hepatitis, alcohol use, medication use, steatosis or steatohepatitis, and cirrhosis. The history should be thorough, with special attention given to the use of medications, vitamins, herbs, drugs, and alcohol; family history; and any history of blood-product transfusions. Other common health conditions, such as diabetes, heart disease, and thyroid disease, can cause or augment liver transaminase elevations. The recent American Gastroenterological Association guideline regarding the evaluation and management of abnormal liver chemistry tests proposes a practical, algorithmic approach when the history and physical examination do not reveal the cause. In addition to liver chemistries, an initial serologic evaluation includes a prothrombin time; albumin; complete blood count with platelets; hepatitis A, B, and C serologies; and iron studies. Depending on the etiology, management strategies may include cessation of alcohol use, attention to medications, control of diabetes, and modification of lifestyle factors such as obesity. If elevations persist after an appropriate period of observation, further testing may include ultrasonography and other serum studies. In some cases, biopsy may be indicated.
Am Fam Physician. 2005 Mar 15;71(6):1105-10.

総胆管結石の腹部CT画像

総胆管に結石がある。
出典
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1: 著者提供

Non alcoholic fatty liver disease

a：NAFL(Non alcoholic fatty liver)
b：NASH(Non alcoholic steatohepatitis)
c：Cirrhosis
(Courtesy of Dr. Lisa M. Yerian)

中等度から著明なアミノトランスフェラーゼ濃度上昇の一般的な原因の生化学特性

AST・ALTとビリルビンの上昇の程度からどのような肝機能障害が起こっているのかを推測することができる。
出典
imgimg
1: Liver enzyme alteration: a guide for clinicians.
著者: Edoardo G Giannini, Roberto Testa, Vincenzo Savarino
雑誌名: CMAJ. 2005 Feb 1;172(3):367-79. doi: 10.1503/cmaj.1040752.
Abstract/Text: Isolated alterations of biochemical markers of liver damage in a seemingly healthy patient can present a challenge for the clinician. In this review we provide a guide to interpreting alterations to liver enzyme levels. The functional anatomy of the liver and pathophysiology of liver enzyme alteration are briefly reviewed. Using a schematic approach that classifies enzyme alterations as predominantly hepatocellular or predominantly cholestatic, we review abnormal enzymatic activity within the 2 subgroups, the most common causes of enzyme alteration and suggested initial investigations.
CMAJ. 2005 Feb 1;172(3):367-79. doi: 10.1503/cmaj.1040752.

肝疾患の診断アルゴリズム

肝機能障害の診断にむけてのおおまかな流れがまとめられている。

無症状のAST・ALT上昇患者の診断へのアプローチ

肝機能障害の診断にむけての対応方法がまとめられている。