Hepatic disease differential diagnosis

Pinos, T., Xiol, X., Herranz, R., Figueras, C., Catala, I. Caroli s disease versus polycystic hepatic disease. Differential diagnosis with Tc-99m DISIDA scintigraphy. Clin. Nucl. Med. 1993 18 664 -667... 

HBD is a biochemical rather than electrophoretic assessment of the LD isoenzyme which is associated with heart. All five isoenzymes of LD exhibit some activity toward cx-hydroxy-butyrate as substrate, but heart LD shows the greatest activity. Serum HBD measurement is not as valuable as the electrophoretic determination of heart LD isoenzyme. High HBD activity has also been found in diseases of the liver. Rises associated with the hepatic effects of congestive heart failure can be disconcerting in the differential diagnosis of myocardial infarction. Wilkinson has used the serum HBD/LD ratio for the differentiation of myocardial disease from other disorders in which HBD activity is elevated, whereas Rosalki has not found the ratio to be helpful (39). 

Suggested Alternatives for Differential Diagnosis Influenza, infectious mononucleosis, hepatitis, leptospirosis, infective endocarditis, malaria, tuberculosis, typhoid fever, cryptococcosis, histoplasmosis, ankylosing spondylitis and undifferentiated spondyloarthropathy, collagen vascular disease, chronic fatigue syndrome, malignancy, and osteomyelitis. 

Suggested Alternatives for Differential Diagnosis Hepatitis, Legionnaires disease, myocarditis, pericarditis, cardiac tamponade, pneumonia, ehrlichiosis, relapsing fever, Rocky Mountain spotted fever, and tularemia. 

The respective lesions in the area of the lobules and portal fields and at the hepatocytes, the mesenchyma and connective tissue differ in intensity from case to case (also depending on the respective stage of the disease) - yet the picture of acute hepatitis predominates. In each case of liver disease which remains unresolved in terms of differential diagnosis, thought must be given to the possibility of acute hepatitis with its wide range of aetiological causes, (s. fig. 22.6)... 

Direct detection of HAV and HAAg in the blood or stools is only necessary for scientific purposes. Serological diagnostics is based on the specific detection of anti-HAV IgM, the presence of which confirms acute viral hepatitis A. In differential diagnosis, it is necessary to rule out acute viral hepatitis E, with which anti-HAV IgM may likewise occur Anti-HAV IgM rises in the serum during the first 2 weeks of the disease, i. e. 3 to 4 weeks after infection. It persists for about 2 or 3... 

As with HAV infection (s. p. 421), the clinical features of viral hepatitis B can be influenced by certain courses of disease. As a result, it can prove difficult to draw up a differential diagnosis, and thus further examination becomes necessary. Some of these initially unpredictable courses of disease may be a considerable impediment to the self-limiting capacity of viral hepatitis B. (s. fig. 22.10)... 

Just as with acute viral hepatitis A and B, an HCV infection can induce extrahepatic manifestations and syndromes. (300,313,357, 358) Such associations with various diseases not only make differential diagnosis very difficult, but they also have an unfavourable influence on the course of disease in certain cases. The capability of the C virus to induce autoimmunity is of special significance, (s. tab. 22.8) (see chapter 34.6.2)... 

Drug-related hepatic damage can mimic almost any liver disease and must, therefore, always be included in the differential diagnosis, (s. tab. 29.6)... 

The distinction between primary biliary cholangitis and primary or secondary sclerosing cholangitis by differential diagnosis may be made substantially more difficult at times owing to special courses of disease, autoimmune hepatitis or overlap syndromes. 

A variety of immunopathies and diseases have been associated with autoimmune hepatitis (20-30%). These association factors can render it more difficult to establish a diagnosis or differential diagnosis as a result, therapy is more problematic, and the prognosis deteriorates. (s. tab. 33.2)... 

Differential diagnosis The following conditions should be excluded (7.) alcohol-induced liver disease, (2.) primary biliary cholangitis (86), (3.) porphyria cutanea tarda (108), and (4.) autoimmune hepatitis (89) or autoimmune cholangitis (132) associated with anti-HCV. 

The differential diagnosis in most areas of the world has malaria at the top of the list. However, the presence of parasitemia in patients partially immune to malaria does not prove that malaria is the cause of the symptoms (48). Other confounding infections include typhoid fever, rickettsial and leptospiral diseases, nontyphoidal salmonellosis, shigellosis, relapsing fever, fulminant hepatitis, and meningococ-cemia. In patients with DIG, the differential diagnosis includes acute leukemia, lupus erythematosus, idiopathic or thrombotic thrombocytopenic purpura and hemolytic uremic syndrome (48). 

Increased Utilization. Secondarily low levels of AAT are seen in the neonatal respiratory distress syndrome, severe neonatal hepatitis, and severe preterminal disease of the pancreas. In nonfatal pancreatitis, levels increase along with those of other APR, and increased levels of complexes with trypsin are probably a better marker for use in either differential diagnosis or prognosis in patients with possible pancreatitis. 

Polyclonal increases in serum immunoglobulins are the normal response to infections. IgG response predominates in autoimmune responses IgA in skin, gut, respiratory, and renal infections and IgM in primary viral infections and bloodstream parasites, such as malaria. Chronic bacterial infections may cause an increase in serum levels of all immunoglobulins. In such cases, estimations of the individual immunoglobulins seldom provide more information than protein electrophoresis. They are of value, however, in the differential diagnosis of liver disease and of intrauterine infections. In primary biliary cirrhosis, the IgM level is greatly increased in chronic active hepatitis, IgG and sometimes IgM are increased and in portal cirrhosis, IgA and sometimes IgG are increased. In intrauterine infections, production of IgM by the fetus increases, and the IgM level in umbilical cord blood is increased. Estimations of IgE are used in the management of asthma and other allergic conditions, especially in children. 

The fasting venous plasma ammonia concentration is useful in the differential diagnosis of encephalopathy when it is unclear if encephalopathy is of an hepatic origin. It is especially helpful in diagnosing Reye s syndrome and the inherited disorders of urea metabolism. However, it is not a useful test to use in patients with laiown liver disease. 

In normal, healthy subjects, the fasting level of serum bile acids is low imd is less than 5 p,mol/liter. This level is greatly increased in various hepatobiliary diseases (A9, B6, F2, F3, P9, S34, Til). For example, some liver diseases and their reported range of fasting serum bile acid concentrations (in brackets) are liver cirrhosis (5-100 pmol/liter), viral hepatitis (78—405 p,mol/liter), and extrahepatic biliary obstruction (5-230 p,mol/liter) (P9). An elevated serum bile acid concentration is highly specific for liver disease, but there is no specificity as to the type of liver disease. Determination of the profile of individual bile acids and calculations such as the cholic to che-nodeoxycholic acid ratio have been proposed as useful in the differential diagnosis of liver disease (P9). In practice, however, there is too much overlap between diseases, so that the pattern of serum bile acids does not normally provide useful diagnostic information. 

Enzymatic estimations are only moderately helpful in distinguishing the various hepatic disorders from each other. The belief that high serum alkaline phosphatase activities are indicative of biliary obstruction while normal or only moderately elevated activities occur in association with hepatocellular damage is now known to be an oversimplification. There is considerable overlap between values in obstructive and nonobstructive hepatic disease (Fig. 10), so that serum alkaline phosphatase elevation or nonelevation in the differential diagnosis of hepatobiliary disease is useful only in a statistical sense (H14). 

A decrease in serum BChE activity may result from a variety of disease and other processes, which need to be considered in the differential diagnosis. These include hepatitis, hepatic cirrhosis, and various drugs. 

Other hepatic responses that can be occupationally related include steatosis, cholestatic injury, hepatoportal sclerosis, and hepatic porphyria. The acute care provider should always consider a toxic chemical etiology in the differential diagnosis of liver disease. 

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