doc_clotaire
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A 32-year-old African American female visits with her family physician to establish care. She has had no remarkable past medical history. She has complained of pain in the right upper quadrant occasionally but lately they have been absent. She is otherwise asymptomatic and is on no medications.
Her physical examination is completely benign.
Her lab work noted her
serum bilirubin = 1. 3 mg/dL;
alanine transaminase (ALT) = 90 units/L;
aspartate transaminase (AST) = 75units/L;
alkaline phosphatase = 450 units/L
The next appropriate step would be to order a(n) ?
A. Angiotensin converting enzyme level
B. Chest x-ray
C. Gamma glutamyl-transpeptidase level (GGT)
D. Hepatitis panel
E. Liver biopsy
CAN YOU MAKE A DIAGNOSIS ?
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| muna
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C.........
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| sachida
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Middle aged female with high billirubin, alk phosphatase
likely diagnosis: primary billiary cirrhosis (1/3 patient are asymptomatic)
Next best test would be Anti-mitochondrial ab test
The best test would be Liver biopsy
Ans: E
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| malkut
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in primary billiary cirrhosis, ALT & AST are often not elevated . GGT is usually elev in PBC. i agree hep biopsy is most accurate test for dx of PBC and PBC is a diff dx here, but so is hepatitis, so the answer can be D.
all i acn say is that the ques is a little evasive
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| neuroblastoma
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HEPATITIS diagnosis
D panel
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| Justice
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Well, I agree that it is best to start with something less invasive...
Here is my humble (D)
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| sachida
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Correct me if I am wrong but alk phosphatase does not rise without billiary involvement
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| sachida
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On other thought, may be we need GGT to confirm involvement of billiary system
b/c alk phosphatase could rise due to other organ involvement e.g intestine
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| doc_clotaire
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Sorry Folks , None of you got the correct answer  ?
I must admit that 's a very hard one , though !
Wanna try again or you want me to post the answer ?
Please let me know ?
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| usmile2
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Are we thinking AFRIAN AMERICAN middle aged women -SARCOIDOSIS- answer would be XRAY looking for hilar adenopathies OR is it ACE LEVELS (not so specific) ?
Edited by usmile2 on 04/18/07 - 09:25 PM
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| Justice
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usmile2 wrote:
Are we thinking AFRIAN AMERICAN middle aged women -SARCOIDOSIS- answer would be XRAY looking for hilar adenopathies OR is it ACE LEVELS (not so specific) ?
You could be very right...
Read here: http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd...
All symptoms are the same as described in the Q stem...
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| Justice
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usmile2 wrote:
Are we thinking AFRIAN AMERICAN middle aged women -SARCOIDOSIS- answer would be XRAY looking for hilar adenopathies OR is it ACE LEVELS (not so specific) ?
If this is sarc-s, the liver should be biopsied... Doing CXR is appropriate but irrelevant... Same about ACE... So, the answer could be (E), which we know is not correct, as stated above
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| girl^interrupted
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CXR should be it.
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| starcraftbw
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Hepatitis 
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| Aashi
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Probably Hepatic sarcoidosis----->do a CXRAY first( BEST intial step)------->ACE levels is only for follow up of t/t ,and not for initial dx------>B
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| doc_clotaire
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CORRECT: B
When the liver panel demonstrates a predominance of transaminase elevation the usual cause is hepatocellular injury – typified by viral hepatitis, autoimmune hepatitis, or injury from medications or toxins (e.g. Halothane, acetaminophen, or poisonous mushrooms). A predominance of alkaline phosphatase elevation suggests cholestatic disease (with bile duct injury or obstruction) or infiltrative disease – neoplastic or granulomatous (e.g. sarcoidosis or tuberculosis). Gamma glutamyl-transpeptidase (GGT) levels tend to parallel alkaline phosphatase elevations that stem from the liver. Measurement of GGT can be a useful confirmatory test, but it is an inducible enzyme. Its levels rise (in the absence of liver disease) in persons who are accustomed to drinking excessive quantities or who take certain medications, such as phenobarbital or phenytoin. Some patients have a mixed (cholestatic and hepatocellular) injury, but most can be categorized in the above manner.
With this particular liver enzyme pattern, the alkaline phosphatase pattern is the more predominant abnormality. The mild transaminase elevation strongly suggests that the increased alkaline phosphatase level is from liver rather than bone.
An infiltrative disorder such as sarcoidosis rarely causes symptoms yet it often produces this enzyme pattern. In this setting, a chest film is prudent to identify bilateral hilar adenopathy, which might suffice to diagnose sarcoidosis. Sarcoidosis occurs 10 times more frequently in black persons. If the chest film shows no abnormality then the possibility of the earliest stage of primary biliary cirrhosis needs to be considered. Abnormal liver enzyme concentration in young women who are asymptomatic is now a common presentation for primary biliary cirrhosis. A positive test for antimitochondrial antibodies would strongly support this diagnosis.
An angiotensin converting enzyme level and a liver biopsy may eventually be required to confirm the diagnosis of sarcoidosis. However, they are not the next appropriate step. In the case of the liver biopsy, sarcoidosis is associated with hepatic granulomas.
Because this liver pattern is inconsistent with primary hepatocellular injury, such as that typically seen in viral hepatitis, it would be a waste of money to order hepatitis serologic tests. In addition, the patient does not have any risk factors that suggest a hepatitis picture.
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| tongsaa
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this is a tough one...
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| nany
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coooool !!!
yes it is tough
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| doc_clotaire
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I know ! 
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| dr in trouble
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Good Q
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