Autoimmune Hepatitis with Case

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.