Examples of host and environmental variables influencing the diagnostic workup in patients assessed for suspected DILI
| Factor | Alternative diagnosis | Diagnostic appraisal |
|---|---|---|
| Age | ||
| <40 years | Wilson's disease | Ceruloplasmin, copper in 24-hour urine, ABCB7 genetic testing |
| >60 years (DILI is most often cholestatic regardless of the drug) | Benign and malignant biliary obstruction | MRI and/or ERCP If inconclusive and damage persists, consider liver biopsy |
| Type of injury | ||
| Cholestatic/mixed | Benign and malignant biliary obstruction | MRI and/or ERCP If inconclusive and damage persists, consider liver biopsy |
| Comorbidities | ||
| 1. Cardiovascular disease (right/congestive heart failure, coronary artery disease) | Ischaemic hepatitis | Towering AST/ALT Search for prior hypotensive episodes Echocardiogram |
| 2. Hyperthyroidism (untreated) | Thyrotoxic hepatitis | T3, T4, TSH |
| 3. Type 1 diabetes mellitus (poorly controlled) | Glycogenic hepatopathy | Consider liver biopsy |
| 4. Pre-existing liver disease (AIH, ALD, NASH, HBV, HCV) | Flare-up of underlying liver disease | Consider liver biopsy |
| Subject behaviour and local burden of infectious diseases | ||
| 1. Sexual transmission | Syphilis | Serology for acute infection |
| 2. Tropical and developing areas (±underlying HIV infection) | Malaria, dengue, tuberculosis, typhoid fever, leptospirosis and others | Specific serology |
| 3. Hepatitis E (exposure to farm animals, consumption of undercooked pork) | Differential diagnosis in acute hepatitis suspected to be DILI39 | Specific serology (anti-HEV IgM and IgG, HEV PCR) |
ALD, alcoholic liver disease; AIH, autoimmune hepatitis; ALT, alanine aminotransferase; AST, aspartate aminotransferase; DILI, drug-induced liver injury; ERCP, endoscopic retrograde cholangio-pancreatography; HEV, hepatitis E virus; NASH, nonalcoholic steatohepatitis; TSH, thyroid-stimulating hormone.