{"id":7849,"date":"2023-12-14T06:30:04","date_gmt":"2023-12-14T09:30:04","guid":{"rendered":"https:\/\/gastropedia.pub\/pt\/?p=7849"},"modified":"2024-08-22T17:33:45","modified_gmt":"2024-08-22T20:33:45","slug":"quando-suspeitar-de-hepatite-autoimune","status":"publish","type":"post","link":"https:\/\/gastropedia.pub\/pt\/gastroenterologia\/quando-suspeitar-de-hepatite-autoimune\/","title":{"rendered":"Quando suspeitar de Hepatite autoimune?"},"content":{"rendered":"<div class=\"pdfprnt-buttons pdfprnt-buttons-post pdfprnt-top-right\"><a href=\"https:\/\/gastropedia.pub\/pt\/wp-json\/wp\/v2\/posts\/7849?print=pdf\" class=\"pdfprnt-button pdfprnt-button-pdf\" target=\"_blank\" ><img decoding=\"async\" src=\"https:\/\/gastropedia.pub\/pt\/wp-content\/plugins\/pdf-print\/images\/pdf.png\" alt=\"image_pdf\" title=\"Ver PDF\" \/><\/a><a href=\"https:\/\/gastropedia.pub\/pt\/wp-json\/wp\/v2\/posts\/7849?print=print\" class=\"pdfprnt-button pdfprnt-button-print\" target=\"_blank\" ><img decoding=\"async\" src=\"https:\/\/gastropedia.pub\/pt\/wp-content\/plugins\/pdf-print\/images\/print.png\" alt=\"image_print\" title=\"Conte\u00fado de impress\u00e3o\" \/><\/a><\/div>\n<p>A Hepatite autoimune \u00e9 uma doen\u00e7a de etiologia desconhecida, descrita por Jon Waldenstrom em 1950, em que ocorre destrui\u00e7\u00e3o progressiva do par\u00eanquima hep\u00e1tico e que pode acarretar cirrose com elevada morbimortalidade na aus\u00eancia de tratamento. A Hepatite autoimune acomete principalmente mulheres jovens, mas pode ser diagnosticada em ambos os sexos, em qualquer faixa et\u00e1ria <sup>(1,2)<\/sup>. A doen\u00e7a caracteriza-se por hipergamaglobulinemia, reatividade de autoanticorpos circulantes, hepatite de interface ao exame histol\u00f3gico, suscetibilidade gen\u00e9tica relacionada a ant\u00edgenos leucocit\u00e1rios humanos (HLA) espec\u00edficos e, ainda, pela resposta favor\u00e1vel ao uso de corticoide e imunossupressores <sup>(3,4)<\/sup>.<\/p>\n\n\n\n<p>O mecanismo patog\u00eanico da Hepatite autoimune \u00e9 multifatorial, com participa\u00e7\u00e3o de agentes desencadeantes (infec\u00e7\u00f5es, drogas, toxinas), predisposi\u00e7\u00e3o gen\u00e9tica e menor toler\u00e2ncia \u00e0 ativa\u00e7\u00e3o imunol\u00f3gica e expans\u00e3o celular efetora (linf\u00f3citos T citot\u00f3xicos CD4\/CD8) <sup>(5)<\/sup>.<\/p>\n\n\n<div class=\"wp-block-image\">\n<figure class=\"aligncenter size-large\"><a href=\"https:\/\/gastropedia.pub\/pt\/wp-content\/uploads\/2024\/01\/FIGURA-1.png\" data-rel=\"penci-gallery-image-content\" ><img fetchpriority=\"high\" decoding=\"async\" width=\"1024\" height=\"654\" src=\"https:\/\/gastropedia.pub\/pt\/wp-content\/uploads\/2024\/01\/FIGURA-1-1024x654.png\" alt=\"\" class=\"wp-image-7850\" srcset=\"https:\/\/gastropedia.pub\/pt\/wp-content\/uploads\/2024\/01\/FIGURA-1-1024x654.png 1024w, https:\/\/gastropedia.pub\/pt\/wp-content\/uploads\/2024\/01\/FIGURA-1-300x192.png 300w, https:\/\/gastropedia.pub\/pt\/wp-content\/uploads\/2024\/01\/FIGURA-1-768x490.png 768w, https:\/\/gastropedia.pub\/pt\/wp-content\/uploads\/2024\/01\/FIGURA-1-1170x747.png 1170w, https:\/\/gastropedia.pub\/pt\/wp-content\/uploads\/2024\/01\/FIGURA-1-585x374.png 585w, https:\/\/gastropedia.pub\/pt\/wp-content\/uploads\/2024\/01\/FIGURA-1.png 1500w\" sizes=\"(max-width: 1024px) 100vw, 1024px\" \/><\/a><figcaption class=\"wp-element-caption\"><strong><br><\/strong><br><strong>Figura 1 &#8211;<\/strong>Mecanismo de les\u00e3o hep\u00e1tica na hepatite autoimune <br>Fonte:<br>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\n\n<p>A les\u00e3o hep\u00e1tica inicia-se com apresenta\u00e7\u00e3o de autoant\u00edgenos pelas c\u00e9lulas apresentadoras de ant\u00edgenos (APCs), com est\u00edmulo \u00e0 diferencia\u00e7\u00e3o de c\u00e9lulas T CD4. As Interleucinas IL-6 e IL-1\u03b2 estimulam a diferencia\u00e7\u00e3o na resposta Th17, com secre\u00e7\u00e3o de citocinas pr\u00f3-inflamat\u00f3rias IL-17 e de IL-6, a qual estimula ainda mais a diferencia\u00e7\u00e3o na resposta Th17. A exposi\u00e7\u00e3o \u00e0 IL-12 estimula a diferencia\u00e7\u00e3o na resposta Th1, com secre\u00e7\u00e3o de Interferon-\u03b3 e indu\u00e7\u00e3o de diferencia\u00e7\u00e3o de mon\u00f3citos. A exposi\u00e7\u00e3o \u00e0 IL-4 estimula a diferencia\u00e7\u00e3o na resposta Th2, que cursa com secre\u00e7\u00e3o de IL-13, IL-4 e IL-10, estimulando a matura\u00e7\u00e3o de c\u00e9lulas B em plasm\u00f3citos e consequente produ\u00e7\u00e3o de autoanticorpos.<\/p>\n\n\n\n<h2 class=\"wp-block-heading\" id=\"h-quando-suspeitar-de-hepatite-autoimune\"><strong>Quando suspeitar de Hepatite Autoimune?<\/strong><\/h2>\n\n\n\n<p>A hepatite autoimune muitas vezes \u00e9 subdiagnosticada. Para que haja suspei\u00e7\u00e3o, precisamos compreender as formas de apresenta\u00e7\u00e3o da doen\u00e7a <sup>(6-7)<\/sup>.<\/p>\n\n\n\n<ul class=\"wp-block-list\">\n<li><strong>Assintom\u00e1tica<\/strong>: 15-20% dos casos, apenas com eleva\u00e7\u00e3o de enzimas hep\u00e1ticas. Ou seja, mesmo na aus\u00eancia de sintomas, na presen\u00e7a de eleva\u00e7\u00e3o de enzimas hep\u00e1ticas, especialmente aminotransferases, deve haver suspeita de HAI e serem solicitados exames para investiga\u00e7\u00e3o etiol\u00f3gica. (<a href=\"https:\/\/gastropedia.com.br\/gastroenterologia\/figado\/abordagem-de-pacientes-com-alteracoes-de-enzimas-hepaticas\/\">confira mais sobre eleva\u00e7\u00e3o de enzimas hep\u00e1ticas neste post<\/a>)<\/li>\n<\/ul>\n\n\n\n<ul class=\"wp-block-list\">\n<li><strong>Hepatite aguda<\/strong>: ocorre em 30% dos casos, sendo caracterizada por sintomas inespec\u00edficos como astenia, anorexia, artralgia, dor abdominal, prurido, icter\u00edcia, col\u00faria e acolia fecal. Menos frequentemente, a HAI \u00e9 diagnosticada no contexto de insufici\u00eancia hep\u00e1tica aguda, com surgimento de encefalopatia, ascite, hemorragia digestiva, com indica\u00e7\u00e3o de transplante hep\u00e1tico em pacientes previamente assintom\u00e1ticos.<\/li>\n<\/ul>\n\n\n\n<ul class=\"wp-block-list\">\n<li><strong>Insidiosa<\/strong>: caracteriza-se por fadiga progressiva, icter\u00edcia flutuante, anorexia, amenorreia e perda ponderal. Os sintomas inespec\u00edficos retardam o diagn\u00f3stico e a doen\u00e7a evolui para a forma cr\u00f4nica.<\/li>\n<\/ul>\n\n\n\n<ul class=\"wp-block-list\">\n<li><strong>Cr\u00f4nica<\/strong>: caracterizada pelo surgimento de altera\u00e7\u00f5es cl\u00ednico-laboratoriais e histol\u00f3gicas caracter\u00edsticas de hepatopatia avan\u00e7ada, com presen\u00e7a ou n\u00e3o de hipertens\u00e3o portal.<\/li>\n<\/ul>\n\n\n\n<p>Dados de uma coorte do Hospital das Cl\u00ednicas da Universidade de S\u00e3o Paulo (HC-FMUSP), composta por 268 portadores de HAI, evidenciou hepatite aguda como forma de apresenta\u00e7\u00e3o mais prevalente (56%), hepatopatia cr\u00f4nica avan\u00e7ada em 25% e diagn\u00f3stico na forma assintom\u00e1tica em 10% dos casos <sup>(8)<\/sup>. H\u00e1, ainda, formas at\u00edpicas de apresenta\u00e7\u00e3o, com acometimento de ductos biliares e aus\u00eancia de reatividade de autoanticorpos circulantes.<\/p>\n\n\n\n<h2 class=\"wp-block-heading\" id=\"h-diagnostico-da-hepatite-autoimune\"><strong>Diagn\u00f3stico da <strong>Hepatite Autoimune<\/strong><\/strong><\/h2>\n\n\n\n<p>Os crit\u00e9rios para diagn\u00f3stico e resposta ao tratamento da hepatite autoimune foram definidos em 1993 e revisados em 1999 pelo Grupo Internacional de Hepatite Autoimune (Figura 2). Apesar dos crit\u00e9rios requererem a exclus\u00e3o de outras etiologias de hepatopatias cr\u00f4nicas com aspectos cl\u00ednico-laboratoriais semelhantes, muitas caracter\u00edsticas da HAI podem estar presentes em outras doen\u00e7as hep\u00e1ticas, como a colangite biliar prim\u00e1ria, colangite esclerosante prim\u00e1ria, hepatopatia induzida por drogas, hepatites virais e esteato-hepatite alco\u00f3lica ou associada ao metabolismo, tornando muitas vezes o diagn\u00f3stico desafiador <sup>(9)<\/sup>.<\/p>\n\n\n\n<p>&nbsp;<\/p>\n\n\n\n<figure class=\"wp-block-table is-style-stripes has-normal-font-size\"><div class=\"pcrstb-wrap\"><table class=\"has-background\" style=\"background-color:#bfc5cc\"><thead><tr><th><strong>Par\u00e2metros<\/strong><\/th><th><strong>Pontua\u00e7\u00e3o<\/strong><\/th><\/tr><\/thead><tbody><tr><td><strong>Sexo Feminino<\/strong><\/td><td><br>+2<\/td><\/tr><tr><td><br><strong>FA\/AST ou ALT <\/strong>(X acima do VN)<\/td><td>&nbsp;<\/td><\/tr><tr><td><br>&lt; 1,5<\/td><td><br>+2<\/td><\/tr><tr><td><br>1,5-3,0<\/td><td><br>0<\/td><\/tr><tr><td><br>&gt;3,0<\/td><td><br>-2<\/td><\/tr><tr><td><br><strong>Gamaglobulina\/IgG (n\u00famero de vezes acima do VN)<\/strong><\/td><td>&nbsp;<\/td><\/tr><tr><td><br>&gt;2,0x<\/td><td><br>+3<\/td><\/tr><tr><td><br>1,5-2,0x<\/td><td><br>+2<\/td><\/tr><tr><td><br>1,0-1,5x<\/td><td><br>+1<\/td><\/tr><tr><td><br>&lt;1,0x<\/td><td><br>0<\/td><\/tr><tr><td><br><strong>Autoanticorpos<\/strong> (FAN\/AML\/LKM1)<\/td><td>&nbsp;<\/td><\/tr><tr><td><br>&gt;1:80<\/td><td><br>+3<\/td><\/tr><tr><td><br>1:80<\/td><td><br>+2<\/td><\/tr><tr><td><br>1:40<\/td><td><br>+1<\/td><\/tr><tr><td><br>&lt; 1:40<\/td><td><br>0<\/td><\/tr><tr><td><strong>Outros marcadores <\/strong>(Anti-SLA\/LP, anti-actina, anti-LC1, p-ANCA)<\/td><td>+2<\/td><\/tr><tr><td><strong>Antimitoc\u00f4dria+<\/strong><\/td><td>-4<\/td><\/tr><tr><td><strong>Marcadores virais<\/strong><br>Anti-VHA IgM, AgHBs, anti-HBc IgM +<\/td><td><br>-3<\/td><\/tr><tr><td>Anti-VHC+ e RNA do VHC +<\/td><td>-3<\/td><\/tr><tr><td>Anti-VHA IgM, AgHBs, anti-HBc IgM ou anti-VHC negativos<\/td><td>+3<\/td><\/tr><tr><td><strong>Uso recente de drogas hepatot\u00f3xicas positiva\/negativa<\/strong><\/td><td>-4\/+1<\/td><\/tr><tr><td><strong>Consumo alco\u00f3lico<\/strong><\/td><td>&nbsp;<\/td><\/tr><tr><td>&lt; 25g\/dia<\/td><td>+2<\/td><\/tr><tr><td>&gt;60g\/dia<\/td><td>-2<\/td><\/tr><tr><td><strong>Outra doen\u00e7a autoimune <\/strong>no paciente ou em familiar de primeiro grau<\/td><td>+2<\/td><\/tr><tr><td><strong>Histologia:<\/strong><\/td><td>&nbsp;<\/td><\/tr><tr><td>Hepatite de Interface<\/td><td>+3<\/td><\/tr><tr><td>Rosetas<\/td><td>+1<\/td><\/tr><tr><td>Plasm\u00f3citos<\/td><td>+1<\/td><\/tr><tr><td>Nenhuma das altera\u00e7\u00f5es acima<\/td><td>-5<\/td><\/tr><tr><td>Altera\u00e7\u00f5es biliares (de CBP e CEP)<\/td><td>-3<\/td><\/tr><tr><td>Altera\u00e7\u00e3o sugestiva de outra etiologia<\/td><td>-3<\/td><\/tr><tr><td><strong>HLA<\/strong> DR3 ou DR4<br>DR7 ou DR13 (varai\u00e7\u00f5es regionais)<\/td><td>+1<\/td><\/tr><tr><td><br><strong>Resposta Terap\u00eautica<\/strong><\/td><td>&nbsp;<\/td><\/tr><tr><td>Completa<\/td><td>+2<\/td><\/tr><tr><td>Recidiva durante ou ap\u00f3s suspens\u00e3o do tratamento ap\u00f3s resposta completa Inicial<\/td><td>+3<\/td><\/tr><\/tbody><\/table><\/div><figcaption class=\"wp-element-caption\"><strong>Figura 2 &#8211;<\/strong><br>Crit\u00e9rios Diagn\u00f3sticos Modificados da HAI pelo Grupo Internacional de Hepatite autoimune. Adaptado<br><sup>(10<em><strong>). <\/strong><\/em><\/sup>Interpreta\u00e7\u00e3o: Antes do tratamento: &gt; 15: diagn\u00f3stico definitivo,\u2264 15 &#8211;<br>10: prov\u00e1vel, Ap\u00f3s tratamento: &gt; 17: diagn\u00f3stico definitivo,\u2264 17 -12: prov\u00e1vel<\/figcaption><\/figure>\n\n\n\n<p>&nbsp;<\/p>\n\n\n\n<p>A suspei\u00e7\u00e3o da hepatite autoimune deve ocorrer em todas as formas de apresenta\u00e7\u00e3o da doen\u00e7a, desde quadros assintom\u00e1ticos, com eleva\u00e7\u00e3o de aminotransferases em exames de rotina (Figura 3), at\u00e9 as formas sintom\u00e1ticas, com presen\u00e7a ou n\u00e3o de hepatopatia cr\u00f4nica avan\u00e7ada. A import\u00e2ncia da suspei\u00e7\u00e3o e do diagn\u00f3stico precoce deve-se ao fato de que o tratamento cl\u00ednico pode induzir remiss\u00e3o cl\u00ednico-laboratorial da doen\u00e7a, prevenir fibrog\u00eanese hep\u00e1tica e a evolu\u00e7\u00e3o para hepatopatia cr\u00f4nica avan\u00e7ada.<\/p>\n\n\n\n<figure class=\"wp-block-image size-full\"><a href=\"https:\/\/gastropedia.pub\/pt\/wp-content\/uploads\/2024\/01\/FIGURA-2.png\" data-rel=\"penci-gallery-image-content\" ><img decoding=\"async\" width=\"696\" height=\"398\" src=\"https:\/\/gastropedia.pub\/pt\/wp-content\/uploads\/2024\/01\/FIGURA-2.png\" alt=\"\" class=\"wp-image-7851\" srcset=\"https:\/\/gastropedia.pub\/pt\/wp-content\/uploads\/2024\/01\/FIGURA-2.png 696w, https:\/\/gastropedia.pub\/pt\/wp-content\/uploads\/2024\/01\/FIGURA-2-300x172.png 300w, https:\/\/gastropedia.pub\/pt\/wp-content\/uploads\/2024\/01\/FIGURA-2-585x335.png 585w\" sizes=\"(max-width: 696px) 100vw, 696px\" \/><\/a><figcaption class=\"wp-element-caption\"><strong>Figura 3 &#8211; <\/strong>Suspei\u00e7\u00e3o de hepatite autoimune em pacientes com eleva\u00e7\u00e3o de aminotransferases (ALT\/AST)<\/figcaption><\/figure>\n\n\n\n<p class=\"has-very-light-gray-to-cyan-bluish-gray-gradient-background has-background\">Leia tamb\u00e9m: <a href=\"https:\/\/gastropedia.com.br\/gastroenterologia\/pancreas\/pancreatite-autoimune\/\" target=\"_blank\" rel=\"noreferrer noopener\">Pancreatite Autoimune<\/a><\/p>\n\n\n\n<h2 class=\"wp-block-heading\" id=\"h-referencias\"><strong>Refer\u00eancias<\/strong><\/h2>\n\n\n\n<ol class=\"wp-block-list\">\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\n\n\n<li>Czaja AJ. Diagnosis and Management of Autoimmune Hepatitis: Current Status and Future Directions. Gut Liver. 2016;10(2):177-203.<\/li>\n\n\n\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\n\n\n<li>Zachou K, Muratori P, Koukoulis GK, Granito A, Gatselis N, Fabbri A, et al. Review article: autoimmune hepatitis &#8212; current management and challenges. Aliment Pharmacol Ther. 2013;38(8):887-913.<\/li>\n\n\n\n<li>Liberal R, Mieli-Vergani G. VD. Autoimmune hepatitis: From mechanisms to therapy. Rev Clin Esp. 2016;216(7):372-83.<\/li>\n\n\n\n<li>Manns MP, Vogel A. Autoimmune hepatitis, from mechanisms to therapy. Hepatology. SEGO; 2006;43(2 SUPPL. 1).<\/li>\n\n\n\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\n\n\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\n\n\n<li>European Association for the Study of the Liver. EASL Clinical Practice Guidelines: Autoimmune Hepatitis. J Hepatol. 2015;63:971-1004.<\/li>\n\n\n\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\n\n\n<h2 class=\"wp-block-heading\" id=\"h-como-citar-este-artigo\"><strong>Como citar este artigo<\/strong><\/h2>\n\n\n\n<p class=\"has-background\" style=\"background-color:#e1e4ec\">Falc\u00e3o LTM. &#8220;Quando suspeitar de Hepatite autoimune?&#8221; Gastropedia 2023, vol. 2. Dispon\u00edvel em: <a href=\"https:\/\/gastropedia.com.br\/?p=7845\" target=\"_blank\" rel=\"noreferrer noopener\">https:\/\/gastropedia.com.br\/gastroenterologia\/figado\/quando-suspeitar-de-hepatite-autoimune<\/a>\/<\/p>\n","protected":false},"excerpt":{"rendered":"<p>A Hepatite autoimune \u00e9 uma doen\u00e7a de etiologia desconhecida, descrita por Jon Waldenstrom em 1950, em que ocorre destrui\u00e7\u00e3o progressiva do par\u00eanquima hep\u00e1tico e que pode acarretar cirrose com elevada&hellip;<\/p>\n","protected":false},"author":5735,"featured_media":7850,"comment_status":"open","ping_status":"open","sticky":false,"template":"","format":"standard","meta":{"_lmt_disableupdate":"","_lmt_disable":"","footnotes":""},"categories":[21,18],"tags":[],"ano":[137],"tipo":[121],"volume":[44],"class_list":["post-7849","post","type-post","status-publish","format-standard","has-post-thumbnail","hentry","category-figado","category-gastroenterologia","ano-137","tipo-assuntos-gerais","volume-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>Quando suspeitar de Hepatite autoimune? 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