الفهرس 
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Abstract
● The mean age was 46.3 ±12.2 years ranging from 19 to 80 years and most of theses patients were males (33 vs.17) with male to female ratio: 1.9:1.
● There was significant increase of HCV RNA level after acute elevation of aminotransferases and/or bilirubin in all patients as compared to HCV RNA level before. The first HCV RNA level was 5.0x105 ± 4.1x105 IU/mL while the next value after elevation of aminotransferases and/or bilirubin was 8.2x105 ±8.4x105 IU/mL.
● Three patients developed acute hepatitis B infection (positive HBsAg and HBcIgM). The HBV DNA level was 6.4x106 ±7.1x106 IU/mL.
● Only one patient was anti HAV IgM positive and developed acute hepatitis A.
● ANA was positive in one patient and ASMA, AMA were positive in another patient. No patients were positive for LKM-1 or pANCA.
● Eight patients had signs of biliary obstruction in the form of dilated IHBR (Intrahepatic biliary radicles) and dilated CBD and other 2 patients had focal lesions that were proved to be HCC by triphasic CT study of the abdomen. They also had portal vein thrombosis.
● Liver biopsy was done in 4 patients. The histopathological examination revealed caseating granuloma in one patient; another biopsy revealed interface hepatitis and the portal tracts showed inflammatory infiltrate containing eosinophils and plasma cells, a picture suggesting autoimmune hepatitis. Another biopsy revealed sclerosing cholangitis associated with steatohepatitis and the 4th biopsy revealed primary biliary cirrhosis.
● The most common etiology of acute elevation of aminotransferases and/or bilirubin in patients with HCV-related chronic liver disease in descending manner was drug induced liver injury (13 patients), biliary obstruction (8 patients), interferon induced hepatitis (5 patients), acute Hepatitis B (3 patients), UTI induced sepsis (3 patients), HCC (2 patients), abdominal tuberculosis (one patient), autoimmune hepatitis (one patient), acute hepatitis A (one patient), small duct PSC (one patient), PBC (one patient), herbal induced hepatitis (one patient), insecticide induced hepatitis (one patient), typhoid fever (one patient), leptospirosis (one patient) and unknown etiology (7 patients).
● There was non-significant difference between patients who developed ACLF and those who didn’t develop (Non-ACLF) as regards age and gender.
● There was significant difference between patients who developed ACLF and those who didn’t develop (Non-ACLF) as regards bilirubin total, bilirubin direct, total protein, albumin and INR (i.e. bilirubin total, bilirubin direct and INR were significantly higher in ACLF group and total protein and albumin were significantly lower in the same group).
● There was non-significant difference between patients who developed ACLF and those who didn’t develop (Non-ACLF) as regards change of level of HCV PCR in studied patients after acute elevation of aminotransferases and/or bilirubin.
● There was significant difference between patients who developed ACLF and those who didn’t develop (Non-ACLF) as regards occurrence of HCC as both 2 cases of HCC in our study developed ACLF but there was non-significant difference between the 2 groups as regards biliary obstruction.
In conclusion:
● Drug-induced liver injury is the most common cause of acute elevation of aminotransferases and/or bilirubin in patients with HCV-related chronic liver disease followed by biliary obstruction.
● Reasonable number of patients with acute elevation of aminotransferases and/or bilirubin might develop ACLF with expected poor outcome.