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Discussion Starter · #1 ·
You are asked to consult on a 62-year-old white female with pruritus for 4 months. She has noted progres-sive fatigue and a 5-lb weight loss. She has intermittent nausea but no vomiting and denies changes in her bowel habits. There is no history of prior alcohol use, blood trans-fusions, or illicit drug use. The patient is widowed and had two heterosexual partners in her lifetime. Her past medical history is significant only for hypothyroidism, for which she takes levothyroxine. Her family history is unremark-able. On examination she is mildly icteric. She has spider angiomata on her torso. You palpate a nodular liver edge 2 cm below the right costal margin. The remainder of the examination is unremarkable. A right upper quadrant ultrasound confirms your suspicion of cirrhosis. You order a complete blood count and a comprehensive metabolic panel. What is the most appropriate next test?
A. 24-hour urine copper
B. Antimitochondrial antibodies (AMA)
C. Endoscopic retrograde cholangiopancreatography (ERCP)
D. Hepatitis B serologies
E. Serum ferritin
 

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Discussion Starter · #3 ·
answer is B. Antimitochondrial antibodies (AMA)

The presence of cirrhosis in an elderly woman with no prior risk factors for viral or alcoholic cirrhosis should raise the possibility of primary biliary cirrhosis (PBC). It is characterized by chronic inflammation and fibrous obliteration of intrahepatic ductules. The cause is unknown, but autoimmunity is assumed, as there is an association with other autoimmune disorders, such as autoimmune thyroiditis, CREST syndrome, and the sicca syndrome. The vast majority of patients with sympto-matic disease are women. The antimitochondrial antibody test (AMA) is positive in over 90% of patients with PBC and only rarely is positive in other conditions. This makes it the most useful initial test in the diagnosis of PBC. Since there are false positives, if AMA is positive a liver biopsy is performed to confirm the diagnosis. The 24-hour urine copper collection is useful in the diagnosis of Wilson’s disease. Hepatic failure from Wilson’s disease typically occurs before age 50. Hemochromatosis may result in cirrhosis. It is associated with lethargy, fatigue, loss of libido, discoloration of the skin, arthralgias, diabetes, and cardiomyopathy. Ferritin levels are usually increased, and the most suggestive laboratory abnormality is an elevated transferrin saturation percentage.
Although hemochromatosis is a possible diagnosis in this case, PBC is more likely in light of the clinical scenario. Although chronic hepatitis B and hepatitis C are certainly in the differential diagnosis and must be ruled out, they are unlikely because of the patient’s history and lack of risk factors.
 
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