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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| Ivil
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Primary Biliary Cirrhosis.. pt may be asympomatic for yrs..
Do Liver Biopsy do DD primay sclerosing cholangitis, autoimmune cholangitis..
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| Ivonne
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I will go with C, since alkaline phosphatase is marker of cholestasis but it is not specific for the biliary tract so to make a better approach to the biliary tract i will correlate with the level of GGT first.
This can be PBC or Sarcoidosis(ACE level would be helpful) or something else...
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| Ivil
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agree with ivonne.. next appropriate step would be C..
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| arlete
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I think it's C, too.
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| Justice
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B. Chest x-ray
I have learned my lesson with AA patients... This may be a sarcoidosis...
We have to exclude pulmonary sarcoidosis first
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| doyoudig
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C. Gamma glutamyl-transpeptidase level (GGT) -- to see if problem lies with liver or billiary duct....
if sarcoidosis Pt should present w/ more symptoms...and various organ involv..that what I would think....
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| Ivonne
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Agree that this patient may need a work up for sarcoidosis as well, but I would hesitate to ask for an x-ray in a women in a reproductive age without a negative pregnancy test...
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| arlete
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doyoudig: sarcoidosis may be very silent, the range of symptoms and severity is large, sometimes hypercalcemia is the first manifestation in patient otherwise asymptomatic.
Ivonne: X-rays are taken without pregnancy test, we only ask the date of last menstrual period.
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| Doc750
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E. I think it's PBC.
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| doyoudig
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docclaire???
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| study_ing
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i woul narrow it down to E and C
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| ing
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E.... or C?
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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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| Ivonne
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How is that possible to ask an x ray as a next step without info of at least Last menstrual period in a woman in a reproductive age. Could you Doc-clotaire give an explanation about it. Thanks
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| doc_clotaire
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History was not an option !
This is USMLE , you have to play their game
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| neuroblastoma
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 goood job guys.. very nice question
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| Justice
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Well, now I see that I learned my lessons well...
Where is this Q from, Doc_clotaire?
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| doc_clotaire
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EXAM MASTER buddy 
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| arlete
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Good one, thanks.
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