Fontana Robert J, Lok Anna S F
Division of Gastroenterology, University of Michigan Health System, Ann Arbor, MI, USA.
Hepatology. 2002 Nov;36(5 Suppl 1):S57-64. doi: 10.1053/jhep.2002.36800.
Hepatic fibrosis is the main determinant of clinical outcomes of chronic hepatitis C. Liver histology is frequently considered the gold standard for assessing hepatic fibrosis. However, liver biopsy is associated with sampling error, interobserver variability, and potential complications. Thus, there is a need for simple, inexpensive, and reliable noninvasive means to assess disease severity in patients with chronic hepatitis C. Clinical examination is unreliable in differentiating different stages of compensated liver disease. Among the routine laboratory tests, decreased platelet count, increase in the ratio of aspartate to alanine aminotransferase (AST/ALT), and prolonged prothrombin time are the earliest indicators of cirrhosis and portal hypertension. Individual serum fibrosis markers have limited accuracy in predicting hepatic fibrosis. Indices composed of a panel of markers correlate better with histological fibrosis, but their reliability requires further validation. Currently, noninvasive monitoring of patients with chronic hepatitis C relies on clinical evaluation, routine laboratory tests, and ultrasound and endoscopic surveillance in patients with cirrhosis. Initial evaluation should focus on assessment of activity and stage of liver disease for prognostication and decisions regarding treatment, and to rule out coinfections and other causes of liver disease. Subsequent follow-up should focus on detection of liver disease progression and the need for treatment. The frequency of monitoring and the tests used will depend on the patient's age, stage of liver disease, and comorbid conditions. There is an urgent need to develop and validate noninvasive tests that can accurately reflect the full spectrum of hepatic inflammation and fibrosis in chronic hepatitis C.
肝纤维化是慢性丙型肝炎临床结局的主要决定因素。肝脏组织学检查常被视为评估肝纤维化的金标准。然而，肝活检存在抽样误差、观察者间差异以及潜在并发症。因此，需要简单、廉价且可靠的非侵入性方法来评估慢性丙型肝炎患者的疾病严重程度。临床检查在区分代偿期肝病的不同阶段时并不可靠。在常规实验室检查中，血小板计数降低、天冬氨酸与丙氨酸转氨酶比值（AST/ALT）升高以及凝血酶原时间延长是肝硬化和门静脉高压最早的指标。单个血清纤维化标志物在预测肝纤维化方面准确性有限。由一组标志物组成的指数与组织学纤维化的相关性更好，但其可靠性仍需进一步验证。目前，慢性丙型肝炎患者的非侵入性监测依赖于临床评估、常规实验室检查以及对肝硬化患者的超声和内镜监测。初始评估应侧重于评估肝病的活动度和阶段，以进行预后判断和治疗决策，并排除合并感染及其他肝病病因。后续随访应侧重于检测肝病进展及治疗需求。监测频率和所采用的检查将取决于患者的年龄、肝病阶段及合并症情况。迫切需要开发并验证能够准确反映慢性丙型肝炎肝炎症和纤维化全貌的非侵入性检查。
