Critères diagnostiques et bilan initial de la cirrhose non compliquée - Diagnosis of uncomplicated cirrhosis 2006 - Quick reference guide - Version anglaise
Mis en ligne le 07 mai 2009 Ces recommandations ont pour objectif d'améliorer le diagnostic de la cirrhose non compliquée, afin d’en traiter la cause et les éventuelles comorbidités, et de prévenir ses complications. Elles ont été élaborées suite à la mise à disposition de méthodes «non invasives» de mesure de la fibrose hépatique. Elles tiennent compte des données cliniques et économiques disponibles sur l’ensemble des méthodes diagnostiques (ponction biopsie hépatique, élastographie impulsionnelle ultrasonore et scores biologiques composites).Elles définissent la démarche diagnostique de la cirrhose non compliquée et abordent les points suivants :circonstances diagnostiques et populations ciblesexamens biologiques nécessaires au diagnosticconsultation spécialisée et confirmation du diagnosticbilan initial, étiologique et de sévérité. Mis en ligne le 07 mai 2009
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English
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QUICK REFERENCE GUIDE
DIAGNOSIS OF UNCOMPLICATED CIRRHOSIS
The World Health Organisation defines cirrhosis as a diffuse process characterised by fibrosis and the conversion of normal liver architecture into structurally abnormal nodules.The following guidelines concern uncomplicated cirrhosis only, i.e. the stage of the disease when patients have few or no symptoms. IN CAUSES OF LIVER DISEASE of alcohol over a long periodExcessive consumption Chronic hepatitis C virus (HCV) infection Metabolic syndrome Chronic hepatitis B virus (HBV) infection Genetic haemochromatosis Autoimmune diseases (particularly primary biliary cirrhosis)
TYPES OF ABNORMALITIES SUGGESTING CIRRHOSIS
Clinical (hard liver, spider angioma, splenomegaly) Biological (thrombopenia, reduction in prothrombin time) Endoscopic (œsophageal varices) Imaging (irregular liver surface, liver atrophy or hypertrophy, signs of portal hypertension) BIOLOGICAL TESTS BEFORE REFERRING THE PATIENT TO A SPECIALIST Haemogram ASAT,Bilirubin (total), serum ALAT,ΧGT and alkaline phosphatase Protein electrophoresis Prothrombin time Glucose, triglycerides, cholesterol Ferritin and transferrin saturation coefficient HBs antigen, anti-HBs and anti-HBc antibodies Anti-HCV antibodies
DIAGNOSTIC TOOLS TO CONFIRM THE DIAGNOSIS
Chronic untreated hepatitis C patients with no comorbidities: 1stline test: a non-invasive procedure (Fibroscan®or Fibrotest®) 2ndline test: a second non-invasive procedure and/or a liver biopsy Other patients: a liver biopsyPRINCIPLE LIMITATIONS·Use appropriate assay techniques; Composite score: ensure proper quality control and age, gender and 5 specimen storage biomarkers ( -·Interpret results with caution: no Fibrotest®macroglobuliallentninipss,inurreterc,lacutia2rnnorhaptoglobin, acute inflammation, haemolysis, apolipoprotein A1, Gilbert’s syndrome, no taking of bilirubin (total),Χ causing elevated bilirubinGT) medicines levels Ultrasound technique·Equipment installed in only a few measuring the speed centres in France Transient elasto raphineavwhetofpropagtaoinfoahra·Does not provide a reliable result in (Fibroscan®)s eobese patients or in patients, such as liver (“liver stiffness) children, with a narrow intercostal s ace Sampling errors may give rise to false · negatives (specimen too small); inter-observer and intra-observer variations Histologicalexamination·Constraints due to stay in hospital and Liver biopsyto precautions to be taken before performing the procedure ·Risk of complications (especially bleeding)
INITIAL STATEMENT OF CIRRHOSIS
Biological tests
Morphological examinations
·
· · · · ·
Bilirubin (total), serum ASAT, ALAT,ΧGT and alkaline phosphatase Prothrombin time, albuminHaemogram a%foeto rotein Abdominal Doppler ultrasound by an experienced operator Oeso ha eal, astric and duodenal endosco
SEVERITY OF CIRRHOSIS
Child-Pugh score
Hepatic encephalopathy Ascites
Bilirubin (total) (mmol/l)
Serum Albumin (g/l)
Prothrombin ratio (%)
1 point
None None
< 35
35 >
2 points
Grade I and II Slight
35 -50
28 - 35
3 points
Grade III and IV Moderate
> 50
< 28
> 50 40 - 50 < 40 J, McIn N, RSiozuzrectteo:ME,rliRnogdeèrsSJ,.BHeénphaatomlooguieJcPl.iniCqirureh,o2sieèm:eéiditno,idirégparJean-PierreBneahom.uPrasi:Flammarionyter.seuqinhneB:nIP,JouamerchirBcestcilaps Médecine-Sciences; 2002. p. 629-41.Ó2002 Flammarion Médecine-Sciences The higher the score, the more severe the disease (class A: 5-6 points; class B: 7-9 points; class C: 10-15 points). This Quick Reference Guide is an English summary of the main points of the French guidelines: “Critères diagnostiques et bilan initial de la cirrhose non compliquée , October 2006. The full guidelines and supporting document (in French) can be found atwww.has-sante.fr