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Dtsch Med Wochenschr 2016; 141(22): 1640-1646
DOI: 10.1055/s-0042-100041
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© Georg Thieme Verlag KG Stuttgart · New York

Erhöhte Leberwerte

Elevated liver enzymes
Axel Holstege
1   Medizinische Klinik 1, Klinikum Landshut
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Publication Date:
04 November 2016 (online)

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Zusammenfassung

Erhöhte Leberwerte sind ein häufiger klinischer Befund bei symptomatischen und asymptomatischen Patienten, der eine weitere Abklärung erfordert. Das Muster der pathologisch veränderten Leberwerte erlaubt eine erste Einordnung. Bei vorwiegender Erhöhung der Transaminasen liegt eine hepatozelluläre Schädigung vor, hinter der sich eine virale Genese, eine genetisch bedingte Stoffwechselerkrankung oder eine medikamentös-toxische Schädigung verbergen kann. Steht die Erhöhung von Cholestaseenzymen im Vordergrund muss durch eine Sonografie zunächst geklärt werden, ob eine intra- oder extrahepatische Ursache der Cholestase vorliegt. Intrahepatische Cholestasen sind auf eine primär biliäre Cholangitis, primär und sekundär sklerosierende Cholangitiden, Störungen der kanalikulären Transporter oder Arzneimittelschäden zurückzuführen. Extrahepatische Cholestasen beruhen im Wesentlichen auf Galleabfluss-Störungen durch Gallensteine oder Tumoren. Eine dritte Gruppe von Leberwerterhöhungen ist durch einen Anstieg der γ-GT charakterisiert. Hinter diesem dritten Enzymmuster verbergen sich toxisch-nutritive, infiltrative und metabolische Lebererkrankungen. Bei der Beurteilung erhöhter Leberenzyme ist zu beachten, dass es neben vielen extrahepatischen Krankheitsursachen auch physiologische Enzymerhöhungen gibt. Niedrige Leberwerterhöhungen bei asymptomatischen Patienten sollten zunächst im Verlauf kontrolliert werden, da sich bei einem Drittel der Betroffenen gering erhöhte Leberwerte spontan normalisieren.

Abstract

Elevated liver enzymes are a frequent finding in both symptomatic and asymptomatic patients necessitating further evaluation to clarify the underlying disease. Three different patterns of increased liver enzymes can be defined to allow for a more precise and rational further diagnostic approach. A predominant increase in transaminase activities reflects a disturbance of hepatocellular integrity which can be found in patients with viral hepatitis, genetic liver diseases like Wilson`s disease or hemochromatosis, and drug-induced liver diseases. A second pattern is characterized by high serum alkaline phosphatase and γ-glutamyltranspeptidase activities indicating cholestatic liver diseases. The next important diagnostic measure in this group is an ultrasound study discerning intra- from extrahepatic cholestasis. Intrahepatic cholestatic diseases include primary and secondary sclerosing cholangitis, genetic disturbances of canalicular membrane transporters or drug-induced liver dieseases. Extrahepatic cholestasis involves obstruction of the large bile ducts by gall stones or tumors. The third enzym pattern is defined by a predominant rise in γ-glutamyl transpeptidase which is observed in alcoholic or non-alcoholic fatty liver disease and infiltrating liver diseases. A rise in liver enzymes is not necessarily indicative of a primary hepatic origin. Extrahepatic diseases often cause similarly increased serum activities. In addition even higher values can be observed under normal conditions during pregnancy or in adolescens. Lower values in asymptomatic patients should only be controlled since more than 30% of elevated transaminases spontaneously normalize during follow-up.

Schlüsselwörter

Leberkrankheiten - Leberenzyme - Cholestase - Transaminasen - alkalische Phosphatase - g-Glutamyltranspeptidase - Differentialdiagnostik

Keywords

Liver disease - serum enzymes - cholestasis - transaminases - alkaline phosphatase - g-glutamyl transpeptidase - differential diagnosis
 

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