{"id":8214,"date":"2024-08-28T18:31:32","date_gmt":"2024-08-28T16:31:32","guid":{"rendered":"https:\/\/gastropedia.pub\/es\/?p=8214"},"modified":"2025-05-10T00:45:09","modified_gmt":"2025-05-09T22:45:09","slug":"cuando-sospechar-de-hepatitis-autoinmune","status":"publish","type":"post","link":"https:\/\/gastropedia.pub\/es\/gastroenterologia\/higado\/cuando-sospechar-de-hepatitis-autoinmune\/","title":{"rendered":"\u00bfCu\u00e1ndo sospechar de Hepatitis autoinmune?"},"content":{"rendered":"<p>La Hepatitis autoinmune es una enfermedad de etiolog\u00eda desconocida, descrita por Jon Waldenstrom en 1950, en la que ocurre una destrucci\u00f3n progresiva del par\u00e9nquima hep\u00e1tico y que puede causar cirrosis con alta morbilidad y mortalidad en ausencia de tratamiento. La Hepatitis autoinmune afecta principalmente a mujeres j\u00f3venes, pero puede ser diagnosticada en ambos sexos, en cualquier grupo etario <sup>(1,2)<\/sup>. La enfermedad se caracteriza por hipergamaglobulinemia, reactividad de autoanticuerpos circulantes, hepatitis de interfaz en el examen histol\u00f3gico, susceptibilidad gen\u00e9tica relacionada con ant\u00edgenos leucocitarios humanos (HLA) espec\u00edficos y, adem\u00e1s, por la respuesta favorable al uso de corticoides e inmunosupresores <sup>(3,4)<\/sup>.<\/p>\n<p>El mecanismo patog\u00e9nico de la Hepatitis autoinmune es multifactorial, con la participaci\u00f3n de agentes desencadenantes (infecciones, drogas, toxinas), predisposici\u00f3n gen\u00e9tica y menor tolerancia a la activaci\u00f3n inmunol\u00f3gica y expansi\u00f3n celular efectora (linfocitos T citot\u00f3xicos CD4\/CD8) <sup>(5)<\/sup>.<\/p>\n<div class=\"wp-block-image\">\n<figure class=\"aligncenter size-large\"><figcaption class=\"wp-element-caption\"><img fetchpriority=\"high\" decoding=\"async\" class=\"alignnone size-full wp-image-8745\" src=\"https:\/\/gastropedia.pub\/es\/wp-content\/uploads\/2024\/08\/HAI1-1.png\" alt=\"\" width=\"2408\" height=\"1526\" srcset=\"https:\/\/gastropedia.pub\/es\/wp-content\/uploads\/2024\/08\/HAI1-1.png 2408w, https:\/\/gastropedia.pub\/es\/wp-content\/uploads\/2024\/08\/HAI1-1-300x190.png 300w, https:\/\/gastropedia.pub\/es\/wp-content\/uploads\/2024\/08\/HAI1-1-1024x649.png 1024w, https:\/\/gastropedia.pub\/es\/wp-content\/uploads\/2024\/08\/HAI1-1-768x487.png 768w, https:\/\/gastropedia.pub\/es\/wp-content\/uploads\/2024\/08\/HAI1-1-1536x973.png 1536w, https:\/\/gastropedia.pub\/es\/wp-content\/uploads\/2024\/08\/HAI1-1-2048x1298.png 2048w, https:\/\/gastropedia.pub\/es\/wp-content\/uploads\/2024\/08\/HAI1-1-1920x1217.png 1920w, https:\/\/gastropedia.pub\/es\/wp-content\/uploads\/2024\/08\/HAI1-1-1170x741.png 1170w, https:\/\/gastropedia.pub\/es\/wp-content\/uploads\/2024\/08\/HAI1-1-585x371.png 585w\" sizes=\"(max-width: 2408px) 100vw, 2408px\" \/><br \/>\n<strong>Figura 1 \u2013<\/strong>Mecanismo de lesi\u00f3n hep\u00e1tica en la hepatitis autoinmune<br \/>\nFuente: Falc\u00e3o, Lydia Te\u00f3filo de Moraes. Estudo randomizado de cloroquina versus azatioprina, em associa\u00e7\u00e3o com prednisona, no tratamento da hepatite autoimune [tese]. S\u00e3o Paulo, Faculdade de Medicina; 2018<\/figcaption><\/figure>\n<\/div>\n<p>La lesi\u00f3n hep\u00e1tica comienza con la presentaci\u00f3n de autoant\u00edgenos por las c\u00e9lulas presentadoras de ant\u00edgenos (APC), con est\u00edmulo a la diferenciaci\u00f3n de c\u00e9lulas T CD4. Las interleucinas IL-6 e IL-1\u03b2 estimulan la diferenciaci\u00f3n en la respuesta Th17, con secreci\u00f3n de citocinas proinflamatorias IL-17 y de IL-6, la cual estimula a\u00fan m\u00e1s la diferenciaci\u00f3n en la respuesta Th17. La exposici\u00f3n a IL-12 estimula la diferenciaci\u00f3n en la respuesta Th1, con secreci\u00f3n de Interfer\u00f3n-\u03b3 e inducci\u00f3n de diferenciaci\u00f3n de monocitos. La exposici\u00f3n a IL-4 estimula la diferenciaci\u00f3n en la respuesta Th2, que cursa con secreci\u00f3n de IL-13, IL-4 e IL-10, estimulando la maduraci\u00f3n de c\u00e9lulas B en plasmocitos y consecuente producci\u00f3n de autoanticuerpos.<\/p>\n<h2 id=\"h-quando-suspeitar-de-hepatite-autoimune\" class=\"wp-block-heading\"><strong>\u00bfCu\u00e1ndo sospechar de Hepatitis Autoinmune?<\/strong><\/h2>\n<p>La hepatitis autoinmune a menudo es subdiagnosticada. Para que haya sospecha, necesitamos comprender las formas de presentaci\u00f3n de la enfermedad <sup>(6-7)<\/sup>.<\/p>\n<ul>\n<li><strong>Asintom\u00e1tica<\/strong>: 15-20% de los casos, solo con elevaci\u00f3n de enzimas hep\u00e1ticas. Es decir, incluso en ausencia de s\u00edntomas, en presencia de elevaci\u00f3n de enzimas hep\u00e1ticas, especialmente aminotransferasas, debe haber sospecha de HAI y se deben solicitar ex\u00e1menes para investigaci\u00f3n etiol\u00f3gica. (<a href=\"https:\/\/gastropedia.pub\/es\/gastroenterologia\/abordaje-de-pacientes-con-alteraciones-en-las-enzimas-hepaticas\/\">consulta m\u00e1s sobre elevaci\u00f3n de enzimas hep\u00e1ticas en este post<\/a>)<\/li>\n<\/ul>\n<ul>\n<li><strong>Hepatitis aguda<\/strong>: ocurre en el 30% de los casos, se caracteriza por s\u00edntomas inespec\u00edficos como astenia, anorexia, artralgia, dolor abdominal, prurito, ictericia, coluria y acolia fecal. Menos frecuentemente, la HAI se diagnostica en el contexto de insuficiencia hep\u00e1tica aguda, con aparici\u00f3n de encefalopat\u00eda, ascitis, hemorragia digestiva, con indicaci\u00f3n de trasplante hep\u00e1tico en pacientes previamente asintom\u00e1ticos.<\/li>\n<\/ul>\n<ul>\n<li><strong>Insidiosa<\/strong>: se caracteriza por fatiga progresiva, ictericia fluctuante, anorexia, amenorrea y p\u00e9rdida de peso. Los s\u00edntomas inespec\u00edficos retrasan el diagn\u00f3stico y la enfermedad evoluciona a la forma cr\u00f3nica.<\/li>\n<\/ul>\n<ul>\n<li><strong>Cr\u00f3nica<\/strong>: se caracteriza por la aparici\u00f3n de alteraciones cl\u00ednico-laboratoriales e histol\u00f3gicas caracter\u00edsticas de hepatopat\u00eda avanzada, con presencia o no de hipertensi\u00f3n portal.<\/li>\n<\/ul>\n<p>Datos de una cohorte del Hospital das Cl\u00ednicas de la Universidad de S\u00e3o Paulo (HC-FMUSP), compuesta por 268 portadores de HAI, evidenci\u00f3 hepatitis aguda como forma de presentaci\u00f3n m\u00e1s prevalente (56%), hepatopat\u00eda cr\u00f3nica avanzada en el 25% y diagn\u00f3stico en la forma asintom\u00e1tica en el 10% de los casos <sup>(8)<\/sup>. Hay, adem\u00e1s, formas at\u00edpicas de presentaci\u00f3n, con afectaci\u00f3n de los conductos biliares y ausencia de reactividad de autoanticuerpos circulantes.<\/p>\n<h2 id=\"h-diagnostico-da-hepatite-autoimune\" class=\"wp-block-heading\"><strong>Diagn\u00f3stico de la <strong>Hepatitis Autoinmune<\/strong><\/strong><\/h2>\n<p>Los criterios para el diagn\u00f3stico y respuesta al tratamiento de la hepatitis autoinmune fueron definidos en 1993 y revisados en 1999 por el Grupo Internacional de Hepatitis Autoinmune (Figura 2). A pesar de que los criterios requieren la exclusi\u00f3n de otras etiolog\u00edas de hepatopat\u00edas cr\u00f3nicas con aspectos cl\u00ednico-laboratoriales similares, muchas caracter\u00edsticas de la HAI pueden estar presentes en otras enfermedades hep\u00e1ticas, como la colangitis biliar primaria, colangitis esclerosante primaria, hepatopat\u00eda inducida por drogas, hepatitis virales y esteato-hepatitis alcoh\u00f3lica o asociada al metabolismo, lo que a menudo hace que el diagn\u00f3stico sea desafiante <sup>(9)<\/sup>.<\/p>\n<figure class=\"wp-block-table is-style-stripes has-normal-font-size\">\n<div class=\"pcrstb-wrap\"><table class=\"has-background\" style=\"background-color: #bfc5cc;\">\n<thead>\n<tr>\n<th><strong>Par\u00e1metros<\/strong><\/th>\n<th><strong>Puntuaci\u00f3n<\/strong><\/th>\n<\/tr>\n<\/thead>\n<tbody>\n<tr>\n<td><strong>Sexo Femenino<\/strong><\/td>\n<td>+2<\/td>\n<\/tr>\n<tr>\n<td><strong>FA\/AST o ALT <\/strong>(X por encima del VN)<\/td>\n<td><\/td>\n<\/tr>\n<tr>\n<td>&lt; 1,5<\/td>\n<td>+2<\/td>\n<\/tr>\n<tr>\n<td>1,5-3,0<\/td>\n<td>0<\/td>\n<\/tr>\n<tr>\n<td>&gt;3,0<\/td>\n<td>-2<\/td>\n<\/tr>\n<tr>\n<td><strong>Gamaglobulina\/IgG (n\u00famero de veces por encima del VN)<\/strong><\/td>\n<td><\/td>\n<\/tr>\n<tr>\n<td>&gt;2,0x<\/td>\n<td>+3<\/td>\n<\/tr>\n<tr>\n<td>1,5-2,0x<\/td>\n<td>+2<\/td>\n<\/tr>\n<tr>\n<td>1,0-1,5x<\/td>\n<td>+1<\/td>\n<\/tr>\n<tr>\n<td>&lt;1,0x<\/td>\n<td>0<\/td>\n<\/tr>\n<tr>\n<td><strong>Auto-anticuerpos<\/strong> (ANA\/AML\/LKM1)<\/td>\n<td><\/td>\n<\/tr>\n<tr>\n<td>&gt;1:80<\/td>\n<td>+3<\/td>\n<\/tr>\n<tr>\n<td>1:80<\/td>\n<td>+2<\/td>\n<\/tr>\n<tr>\n<td>1:40<\/td>\n<td>+1<\/td>\n<\/tr>\n<tr>\n<td>&lt; 1:40<\/td>\n<td>0<\/td>\n<\/tr>\n<tr>\n<td><strong>Otros marcadores <\/strong>(Anti-SLA\/LP, anti-actina, anti-LC1, p-ANCA)<\/td>\n<td>+2<\/td>\n<\/tr>\n<tr>\n<td><strong>Antimitocondria+<\/strong><\/td>\n<td>-4<\/td>\n<\/tr>\n<tr>\n<td><strong>Marcadores virales<\/strong><br \/>\nAnti-VHA IgM, AgHBs, anti-HBc IgM +<\/td>\n<td>-3<\/td>\n<\/tr>\n<tr>\n<td>Anti-VHC+ y RNA del VHC +<\/td>\n<td>-3<\/td>\n<\/tr>\n<tr>\n<td>Anti-VHA IgM, AgHBs, anti-HBc IgM o anti-VHC negativos<\/td>\n<td>+3<\/td>\n<\/tr>\n<tr>\n<td><strong>Uso reciente de drogas hepatot\u00f3xicas positiva\/negativa<\/strong><\/td>\n<td>-4\/+1<\/td>\n<\/tr>\n<tr>\n<td><strong>Consumo alcoh\u00f3lico<\/strong><\/td>\n<td><\/td>\n<\/tr>\n<tr>\n<td>&lt; 25g\/d\u00eda<\/td>\n<td>+2<\/td>\n<\/tr>\n<tr>\n<td>&gt;60g\/d\u00eda<\/td>\n<td>-2<\/td>\n<\/tr>\n<tr>\n<td><strong>Otra enfermedad autoinmune <\/strong>en el paciente o en un familiar de primer grado<\/td>\n<td>+2<\/td>\n<\/tr>\n<tr>\n<td><strong>Histolog\u00eda:<\/strong><\/td>\n<td><\/td>\n<\/tr>\n<tr>\n<td>Hepatitis de Interfaz<\/td>\n<td>+3<\/td>\n<\/tr>\n<tr>\n<td>Rosetas<\/td>\n<td>+1<\/td>\n<\/tr>\n<tr>\n<td>Plasmocitos<\/td>\n<td>+1<\/td>\n<\/tr>\n<tr>\n<td>Ninguna de las alteraciones anteriores<\/td>\n<td>-5<\/td>\n<\/tr>\n<tr>\n<td>Alteraciones biliares (de CBP y CEP)<\/td>\n<td>-3<\/td>\n<\/tr>\n<tr>\n<td>Alteraci\u00f3n sugestiva de otra etiolog\u00eda<\/td>\n<td>-3<\/td>\n<\/tr>\n<tr>\n<td><strong>HLA<\/strong> DR3 o DR4<br \/>\nDR7 o DR13 (variaciones regionales)<\/td>\n<td>+1<\/td>\n<\/tr>\n<tr>\n<td><strong>Respuesta Terap\u00e9utica<\/strong><\/td>\n<td><\/td>\n<\/tr>\n<tr>\n<td>Completa<\/td>\n<td>+2<\/td>\n<\/tr>\n<tr>\n<td>Recidiva durante o despu\u00e9s de la suspensi\u00f3n del tratamiento despu\u00e9s de la respuesta completa inicial<\/td>\n<td>+3<\/td>\n<\/tr>\n<\/tbody>\n<\/table><\/div><figcaption class=\"wp-element-caption\"><strong>Figura 2 \u2013<\/strong><br \/>\nCriterios Diagn\u00f3sticos Modificados de la HAI por el Grupo Internacional de Hepatitis autoinmune. Adaptado <sup>(10<em><strong>). <\/strong><\/em><\/sup>Interpretaci\u00f3n: Antes del tratamiento: &gt; 15: diagn\u00f3stico definitivo, \u226415 \u2013<br \/>\n10: probable. Despu\u00e9s del tratamiento: &gt; 17: diagn\u00f3stico definitivo,\u00a0 \u226417 -12: probable<\/figcaption><\/figure>\n<p>La sospecha de hepatitis autoinmune debe ocurrir en todas las formas de presentaci\u00f3n de la enfermedad, desde cuadros asintom\u00e1ticos, con elevaci\u00f3n de aminotransferasas en ex\u00e1menes de rutina (Figura 3), hasta las formas sintom\u00e1ticas, con presencia o no de hepatopat\u00eda cr\u00f3nica avanzada. La importancia de la sospecha y del diagn\u00f3stico precoz se debe al hecho de que el tratamiento cl\u00ednico puede inducir remisi\u00f3n cl\u00ednico-laboratorial de la enfermedad, prevenir la fibrosis hep\u00e1tica y la evoluci\u00f3n a hepatopat\u00eda cr\u00f3nica avanzada.\u00a0<img decoding=\"async\" class=\"alignnone size-full wp-image-8747\" src=\"https:\/\/gastropedia.pub\/es\/wp-content\/uploads\/2024\/08\/HAI2-1.png\" alt=\"\" width=\"2582\" height=\"1590\" srcset=\"https:\/\/gastropedia.pub\/es\/wp-content\/uploads\/2024\/08\/HAI2-1.png 2582w, https:\/\/gastropedia.pub\/es\/wp-content\/uploads\/2024\/08\/HAI2-1-300x185.png 300w, https:\/\/gastropedia.pub\/es\/wp-content\/uploads\/2024\/08\/HAI2-1-1024x631.png 1024w, https:\/\/gastropedia.pub\/es\/wp-content\/uploads\/2024\/08\/HAI2-1-768x473.png 768w, https:\/\/gastropedia.pub\/es\/wp-content\/uploads\/2024\/08\/HAI2-1-1536x946.png 1536w, https:\/\/gastropedia.pub\/es\/wp-content\/uploads\/2024\/08\/HAI2-1-2048x1261.png 2048w, https:\/\/gastropedia.pub\/es\/wp-content\/uploads\/2024\/08\/HAI2-1-1920x1182.png 1920w, https:\/\/gastropedia.pub\/es\/wp-content\/uploads\/2024\/08\/HAI2-1-1170x720.png 1170w, https:\/\/gastropedia.pub\/es\/wp-content\/uploads\/2024\/08\/HAI2-1-585x360.png 585w\" sizes=\"(max-width: 2582px) 100vw, 2582px\" \/><\/p>\n<figure class=\"wp-block-image size-full\"><figcaption class=\"wp-element-caption\"><strong>Figura 3 \u2013 <\/strong>Sospecha de hepatitis autoinmune en pacientes con elevaci\u00f3n de aminotransferasas (ALT\/AST)<\/figcaption><\/figure>\n<p class=\"has-very-light-gray-to-cyan-bluish-gray-gradient-background has-background\">Lea tambi\u00e9n: <a href=\"https:\/\/gastropedia.pub\/es\/gastroenterologia\/pancreas\/pancreatitis-autoinmune\/\" target=\"_blank\" rel=\"noreferrer noopener\">Pancreatitis Autoinmune<\/a><\/p>\n<h2 id=\"h-referencias\" class=\"wp-block-heading\"><strong>Referencias<\/strong><\/h2>\n<ol>\n<li>Manns MP, Czaja AJ, Gorham JD, Krawitt EL, Mieli-Vergani G, Vergani D, et al. Diagnosis and management of autoimmune hepatitis. Hepatology. 2010;51(6):2193-213.<\/li>\n<li>Czaja AJ. Diagnosis and Management of Autoimmune Hepatitis: Current Status and Future Directions. Gut Liver. 2016;10(2):177-203.<\/li>\n<li>Lohse AW, Mieli-Vergani G. Autoimmune hepatitis. J Hepatol. European Association for the Study of the Liver. 2011;55(1):171-82.<\/li>\n<li>Zachou K, Muratori P, Koukoulis GK, Granito A, Gatselis N, Fabbri A, et al. Review article: autoimmune hepatitis \u2014 current management and challenges. Aliment Pharmacol Ther. 2013;38(8):887-913.<\/li>\n<li>Liberal R, Mieli-Vergani G. VD. Autoimmune hepatitis: From mechanisms to therapy. Rev Clin Esp. 2016;216(7):372-83.<\/li>\n<li>Manns MP, Vogel A. Autoimmune hepatitis, from mechanisms to therapy. Hepatology. SEGO; 2006;43(2 SUPPL. 1).<\/li>\n<li>Bittencourt PL, Can\u00e7ado ELR, Couto CA, Levy C, Porta G, Silva AEB, et al. Brazilian society of hepatology recommendations for the diagnosis and management of autoimmune diseases of the liver. Arq Gastroenterol. 2015;52:15-46.<\/li>\n<li>Terrabuio DBR. 20 anos de hepatite auto-imune no Hospital das Cl\u00ednicas da Faculdade de Medicina da Universidade de S\u00e3o Paulo [Disserta\u00e7\u00e3o]. USP; 2006.<\/li>\n<li>European Association for the Study of the Liver. EASL Clinical Practice Guidelines: Autoimmune Hepatitis. J Hepatol. 2015;63:971-1004.<\/li>\n<li>Alvarez F, Berg PA, Bianchi FB, Bianchi L, Burroughs AK, Can\u00e7ado EL, et al. International Autoimmune Hepatitis Group Report: review of criteria for diagnosis of autoimmune hepatitis. J Hepatol 1999;31(5): 929-38.<\/li>\n<\/ol>\n<h2 class=\"wp-block-heading\"><strong>C\u00f3mo citar este art\u00edculo<\/strong><\/h2>\n<p class=\"has-background\" style=\"background-color: #ccd9d4;\">Falc\u00e3o LTM, Gamarra ACQ.\u00a0 \u00bfCu\u00e1ndo sospechar de Hepatitis autoimune? Gastropedia 2024, vol. 2. Disponible en: <a href=\"https:\/\/gastropedia.pub\/es\/gastroenterologia\/higado\/cuando-sospechar-de-hepatitis-autoinmune\/\">https:\/\/gastropedia.pub\/es\/gastroenterologia\/higado\/cuando-sospechar-de-hepatitis-autoinmune\/<\/a><\/p>\n","protected":false},"excerpt":{"rendered":"<p>La Hepatitis autoinmune es una enfermedad de etiolog\u00eda desconocida, descrita por Jon Waldenstrom en 1950, en la que ocurre una destrucci\u00f3n progresiva del par\u00e9nquima hep\u00e1tico y que puede causar cirrosis&hellip;<\/p>\n","protected":false},"author":5740,"featured_media":8213,"comment_status":"open","ping_status":"open","sticky":false,"template":"","format":"standard","meta":{"_lmt_disableupdate":"no","_lmt_disable":"","footnotes":""},"categories":[18,21],"tags":[],"ano":[395],"tipo":[121],"volumen":[44],"class_list":["post-8214","post","type-post","status-publish","format-standard","has-post-thumbnail","hentry","category-gastroenterologia","category-higado","ano-395","tipo-temas-generales","volumen-volume-ii"],"yoast_head":"<!-- This site is optimized with the Yoast SEO Premium plugin v27.2 (Yoast SEO v27.3) - https:\/\/yoast.com\/product\/yoast-seo-premium-wordpress\/ -->\n<title>\u00bfCu\u00e1ndo sospechar de Hepatitis autoinmune? 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