Autoimmune Hepatitis with Case

by Kelley Chuang, MD

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    00:02 Let's begin our next case.

    00:04 A 54-year-old woman presents to the clinic complaining of fatigue and a dull ache in her right abdomen.

    00:11 She has a past medical history of Grave's disease.

    00:14 She takes no medications except methimazole.

    00:17 Her vitals are normal.

    00:18 Physical exam reveals hepatomegaly and mild tenderness to palpation over the right upper quadrant.

    00:25 Her labs show a serum AST of 1300 (U/L) and ALT of 1250 (U/L).

    00:32 Alkaline phosphatase and bilirubin are both normal.

    00:35 Her viral hepatitis serologies are unremarkable and an anti-smooth muscle antibody is positive.

    00:42 So what is the most likely diagnosis? So she has some vague symptoms with a history of autoimmune disease.

    00:52 She does have hepatomegaly and a right upper quadrant tenderness on exam which helps you localize something to the liver.

    01:00 And her labs are notable for a hepatocellular injury pattern, so a predominant elevation in the AST and ALT.

    01:10 In addition, she has this positive anti-smooth muscle antibody.

    01:13 We'll discuss what that means.

    01:17 So let's now talk about autoimmune hepatitis.

    01:21 This is a condition that affects mostly women.

    01:25 It is like many other autoimmune conditions, associated with other autoimmune diseases.

    01:31 So once you have one, it's very likely to develop another.

    01:35 It's presentation can range from either asymptomatic to acute liver failure.

    01:41 The diagnosis is made by looking for a mild to moderate elevation in your transaminases.

    01:48 Because the presentation can be very similar to other types of liver injury, you must also rule out viral hepatitis, Wilson's disease and alcohol or drug induced liver injury.

    02:00 and the diagnosis should be confirmed with a positive autoantibody.

    02:04 So here listed here on the right are some of the autoantibodies that are associated with autoimmune hepatitis.

    02:11 They include an ANA, an antimitochondrial antibody, a smooth muscle antibody and an anti-liver-kidney-microsomal antibody.

    02:22 In general, the gold standard for diagnosis is liver biopsy but because this is so invasive, it is sometimes not done.

    02:31 Lastly, the treatment for this condition involves glucocorticoids or azothioprine.

    02:39 So now we go back to our case.

    02:41 We have a 55-year-old woman with vague symptoms.

    02:44 She does have a history of autoimmune disease with her Grave's disease.

    02:48 She has a hepatocellular pattern of injury on her labs with hepatomegaly.

    02:52 And this anti-smooth muscle antibody being positive really helps us make the diagnosis.

    02:58 Note that this antibody may be positive in autoimmune hepatitis or primary sclerosing cholangitis but in this whole clinical picture, we know now that she most likely has autoimmune hepatitis.

    About the Lecture

    The lecture Autoimmune Hepatitis with Case by Kelley Chuang, MD is from the course Disorders of the Hepatobiliary Tract.

    Included Quiz Questions

    1. Glucocorticoids
    2. Azithromycin
    3. Lactulose
    4. Phlebotomy
    5. Trientine
    1. Anti-smooth muscle antibody
    2. Antihistone antibody
    3. Anti-Smith antibody
    4. Anticentromere antibody
    5. Antineutrophil cytoplasmic antibody

    Author of lecture Autoimmune Hepatitis with Case

     Kelley Chuang, MD

    Kelley Chuang, MD

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