An asymptomatic 48-year-old Caucasian female with a history of hypothyroidism is being evaluated for abnormal liver function tests. She has no other medical problems. She takes thyroxine for the hypothyroidism. She takes no herbal medication. She never smoked or used IV drugs, and rarely drinks alcohol. Her family history is unremarkable. Her blood pressure is 120/80 mmHg, pulse is 72/min, temperature is 36.7C (98F) and respirations are 14/min. The physical examination is normal, except for mild, painless hepatomegaly. The initial lab test results are as follows:
What is the most appropriate next step in the management of this patient?

Question

An asymptomatic 48-year-old Caucasian female with a history of hypothyroidism is being evaluated for abnormal liver function tests.  She has no other medical problems.  She takes thyroxine for the hypothyroidism.  She takes no herbal medication.  She never smoked or used IV drugs, and rarely drinks alcohol.  Her family history is unremarkable.  Her blood pressure is 120/80 mmHg, pulse is 72/min, temperature is 36.7C (98F) and respirations are 14/min.  The physical examination is normal, except for mild, painless hepatomegaly.  The initial lab test results are as follows:
 What is the most appropriate next step in the management of this patient?

Quizplus · Accepted Answer

Explanation: Autoimmune hepatitis causes progressive parenchymal liver damage. Its course is variable, and severe cases can progress to cirrhosis and liver failure in 6 months. Most cases occur in young to middle-aged women. Autoimmune manifestations such as arthritis, erythema nodosum, thyroiditis, pleurisy, pericarditis, anemia and sicca syndrome are common. Common findings include elevated AST and ALT levels, a normal or near-normal alkaline phosphatase level, and a normal bilirubin level. Autoantibodies are common, and the most typical are antinuclear antibodies (in a homogeneous staining pattern, hence the term "lupoid hepatitis") and anti-smooth muscle antibodies (against actin). (Choice C) Antimitochondrial antibodies are sensitive and specific for primary biliary cirrhosis (PBC), which is rather unlikely in this patient. PBC is characterized by an elevated alkaline phosphatase level rather than elevated aminotransferase levels. (Choice A) The usual cause of high gamma-glutamyl transferase (GGT) is cholestasis. GGT is useful to differentiate whether the elevated alkaline phosphatase level is from liver or bone. Checking GGT will not contribute to this patient's diagnosis. (Choice E) Alpha-1 antitrypsin deficiency causes progressive liver failure and emphysema without signs of autoimmunity. Liver abnormalities are usually seen during the first two decades of life, and patients develop clinical features of emphysema. (Choice D) ERCP is used in cases that have more of a cholestatic picture. It is the gold standard for the diagnosis of sclerosing cholangitis, which is usually seen in patients with ulcerative colitis. ERCP has a better resolution than MR cholangiography, and is therefore more sensitive in the detection of damaged small bile ducts. Educational Objective: Autoimmune hepatitis is a disease of young to middle-aged women. Common findings include elevated AST and ALT levels, a normal or near-normal alkaline phosphatase level, and a normal bilirubin level. The most specific tests are antinuclear antibodies (homogeneous staining pattern) and anti-smooth muscle antibodies.

An Asymptomatic 48-Year-Old Caucasian Female with a History of Hypothyroidism Is