354.2 🩺 國考版

354.2.1 高頻考點

354.2.1.1 LFT Patterns

  • Hepatocellular: AST/ALT elevation
  • Cholestatic: ALP/GGT elevation
  • Mixed
  • Isolated hyperbilirubinemia

354.2.1.2 AST:ALT Ratio

  • 2: alcohol (typically with high GGT)

  • 1: cirrhosis, muscle disease

  • < 1: most chronic liver disease

354.2.1.3 Bilirubin Metabolism

  • Heme → biliverdin → unconjugated → liver UGT1A1 → conjugated → bile

354.2.1.4 Gilbert Syndrome

  • UGT1A1 mutation
  • Benign, common (5-10%)
  • ↑ With fasting, stress
  • No treatment

354.2.1.5 Crigler-Najjar

  • Type I: severe; kernicterus risk; phototherapy, liver transplant
  • Type II: partial; phenobarbital responsive

354.2.1.6 Dubin-Johnson

  • MRP2 mutation
  • Conjugated; dark liver

354.2.1.7 Rotor Syndrome

  • OATP mutation
  • Conjugated; liver not pigmented

354.2.1.8 Jaundice Categories

  • Pre-hepatic: hemolysis (unconjugated)
  • Hepatic: dysfunction (mixed)
  • Post-hepatic: cholestasis (conjugated)

354.2.1.9 Cholestatic Pattern

  • ALP + GGT elevation
  • Direct bilirubin
  • Pruritus
  • Dark urine + pale stool

354.2.1.10 Cholestatic Causes

  • Extrahepatic obstruction (stones, cancer)
  • Intrahepatic (PBC, PSC, drugs, sepsis, pregnancy)

354.2.1.11 Acute Hepatitis (ALT > 1000)

  • Drug (acetaminophen)
  • Viral (HAV, HBV, HCV, HEV)
  • Autoimmune (rare this high)
  • Ischemic
  • Wilson (fulminant)
  • HSV

354.2.1.12 Liver Biopsy Indications

  • Unclear etiology
  • Staging
  • Specific diseases
  • Coagulopathy / ascites: transjugular

354.2.1.13 Non-Invasive Fibrosis Scores

  • FIB-4 (age + AST + ALT + platelets)
  • NAFLD Fibrosis Score (NFS)
  • ELF (Enhanced Liver Fibrosis)
  • FibroScan (transient elastography)
  • MR elastography (most accurate)

354.2.2 易混淆比范

Disorder Bilirubin UGT/MRP Treatment
Gilbert Unconjugated ↑ UGT1A1 partial None
Crigler-Najjar I Unconjugated very high UGT1A1 severe Phototherapy, transplant
Crigler-Najjar II Unconjugated moderate UGT1A1 partial Phenobarbital
Dubin-Johnson Conjugated ↑ MRP2 Benign
Rotor Conjugated ↑ OATP Benign

354.2.3 Special Topics

354.2.3.1 Drug-Induced Liver Injury (DILI)

  • Many drugs implicated
  • Pattern: hepatocellular, cholestatic, mixed
  • Predictable (acetaminophen) vs idiosyncratic
  • Roussel Uclaf Causality Assessment Method (RUCAM)
  • Stop drug + supportive

354.2.3.2 Cholestasis of Pregnancy

  • 3rd trimester typically
  • Pruritus + ↑ bile acids
  • Ursodeoxycholic acid + delivery
  • Increases fetal risk

354.2.3.3 Sepsis-Induced Cholestasis

  • Multifactorial
  • Common in ICU
  • Address sepsis

354.2.3.4 TPN-Induced Cholestasis

  • Prolonged TPN
  • Adjust composition
  • Cyclic TPN
  • SMOFlipid (fish oil-based) may help