Assessment of drug-induced hepatotoxicity in clinical practice: A challenge for gastroenterologists

Table 4 Clinical work-up to identify other possible causes of liver disease

Test	Condition	Commentary
Viral serology	Viral hepatitis	Less frequent in older patients, especially Hepatitis A, search for epidemiologic risk factors, outcome may be similar to that of DILI following de-challenge.
IgM anti-HAV
IgM anti-HBc
Anti-HCV, RNA-HCV (RT-PCR)
IgM-CMV
IgM-EBV
Herpes virus
Bacterial serology: Salmonella, Campylobacter, Listeria, Coxiella	Bacterial hepatitis	If persistent fever and/or diarrhea
Serology for syphilis	Secondary syphilis	Multiple sexual partners. Disproportionately high serum AP levels.
Autoimmunity (ANA, ANCA, AMA, ASMA, anti-LKM-1)	Autoimmune hepatitis, Primary biliary cirrhosis	Women, ambiguous course following de-challenge. Other autoimmunity features.
AST/ALT ratio > 2	Alcoholic hepatitis	Alcohol abuse. Moderate increase in transaminases despite severity at presentation
Ceruloplasmine, urine cooper	Wilson’s disease	Patients < 40 yr
Alfa-1 antitrypsin	Deficit of α-1 antitrypsin	Pulmonary disease
Transferrin saturation	Hemochromatosis	In anicteric hepatocellular damage. Middle-aged men and older women.
Brilliant eco texture of the Liver.	Non-alcoholic steatohepatitis	In anicteric hepatocellular damage. Obesity, Metabolic syndrome.
Transaminase levels markedly high	Ischemic hepatitis	Disproportionately high AST levels. Hypotension, shock, recent surgery, heart failure, antecedent vascular disease, elderly
Dilated bile ducts by image procedures (AU, CT, MRCP and ERCP)	Biliary obstruction	Colic abdominal pain, cholestatic/mixed pattern.

ALT: alanine aminotransferase; AP: alkaline phosphatase; AST: aspartate aminotransferase; AU: abdominal ultrasound examination; Anti-HAV: Hepatitis A antibody; Anti-HBc: Hepatitis B core antibody; Anti-HCV: Hepatitis C antibody; anti-LKM-1: Liver-kidney microsomal antibody type 1; AMA: antimitochondrial antibody; ANA: antinuclear antibody; ANCA: perinuclear antineutrophil cytoplasmic antibody; ASMA: antismooth muscle antibody; BPC: Biliary primary cirrhosis; CMV: cytomegalovirus; CT: computed tomography; EBV: Epstein-Barr virus; ERCP: Endoscopic retrograde cholangiography; MRCP: Magnetic resonance cholangiography.