Very high serum transaminases (ALT/AST > 1000 lU/L) are seen in the following conditions except-
Correct Answer: Alcoholic liver disease
Description: Investigations Investigations aim to establish alcohol misuse, exclude alternative or additional coexistent causes of liver disease, and assess the severity of liver damage. The clinical history from patient, relatives and friends is impoant to establish alcohol misuse duration and severity. Biological markers, paicularly macrocytosis in the absence of anaemia, may suggest and suppo a history of alcohol misuse. A raised GGT is not specific for alcohol misuse and may also be elevated in the presence of other conditions, including NAFLD. The level may therefore not return to normal with abstinence if chronic liver disease is present, and GGT should not be relied on as an indicator of ongoing alcohol consumption. The presence of jaundice may suggest alcoholic hepatitis. Determining the extent of liver damage often requires a liver biopsy. In alcoholic hepatitis, PT and bilirubin are used to calculate a 'discriminant function' (DF), also known as the Maddrey score, which enables the clinician to assess prognosis (PT = prothrombin time; serum bilirubin in umol/L is divided by 17 to conve to mg/dL): DF Increase in PT Bilirubin mg/dL = x ( ) + A value over 32 implies severe liver disease with a poor prognosis and is used to guide treatment decisions (see below). A second scoring system, the Glasgow score, uses the age, white cell count and renal function, in addition to PT and bilirubin, to assess prognosis and has a cut-off of 9 . Biochemical tests There is no single diagnostic blood test for NAFLD. Elevations of serum ALT and AST are modest, and usually less than twice the upper limit of normal. ALT levels fall as hepatic fibrosis increases and the characteristic AST:ALT ratio of <1 seen in NASH reverses (AST:ALT >1) as disease progresses towards cirrhosis, meaning that steatohepatitis with advanced disease may be present even in those with normal-range ALT levels. 9Other laboratory abnormalities that may be present include non-specific elevations of GGT, low-titre antinuclear antibody (ANA) in 20-30% of patients and elevated ferritin levels. Ref Davidson edition23rd pg884
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