Managing LFT s in General Practice

Transcription

1 Managing LFT s in General Practice Sulleman Moreea FRCP(Edin Edin) ) FRCS(Glasg Glasg) Consultant Gastroenterologist/Hepatologist Bradford Hospitals Trust

2 The normal liver

3 Managing LFT s History and examination Investigations When to refer

4 Managing LFT s Understanding LFT s Interpreting abnormal LFT s In relation to common causes of liver disease Cases Who to refer

5 Understanding LFT s LFT s Synthetic function

6 Liver (mal)function Tests Bilirubin ALT Alkaline Phosphatase ALP

7 LFT s - source Bilirubin breakdown of haemoglobin Spleen Bilirubin transported attached to albumin Uptake by liver Conjugated and excreted in bile Stercobilinogen and urobilinogen

8 LFT s - source Bilirubin ALT - hepatocytes

9 LFT s - source Bilirubin ALT - hepatocytes Alkaline Phosphatase ALP Biliary system

10 LFT s - source Bilirubin ALT Alkaline Phosphatase ALP Biliary system Bone Placenta

11 LFT s other tests Bilirubin ALT Alkaline Phosphatase ALP γgt AST

12 LFT s other tests Bilirubin ALT Alkaline Phosphatase ALP γgt biliary system alcohol

13 LFT s other tests Bilirubin ALT Alkaline Phosphatase ALP γgt AST hepatocyte Used as AST/ALT ratio mainly AST/ALT > 2 suggestive of alcohol liver disease

14 Synthetic function Albumin Prothrombin Time - PT

15 Deranged LFT s Raised bilirubin jaundice Raised ALT/ALP in isolation Dissociated transaminitis

16 Deranged LFT s Raised bilirubin jaundice

17 Jaundice - causes 1 Pre-hepatic

18 Jaundice - causes 1 2 Hepatic

19 Jaundice - causes 1 2 Obstructive 3

20 Pre-hepatic jaundice 1 Bil ALT ALP

21 Isolated Raised Bilirubin Increased bilirubin production Haemolysis Decreased uptake in the liver Inborn problems

22 Isolated raised bilirubin Investigations Split bilirubin conjugated/unconjugated unconjugated Reticulocyte count

23 Isolated raised bilirubin Split bilirubin conjugated/unconjugated unconjugated Reticulocyte count Gilbert s syndrome Crigler-Najar type II

24 Obstructive Jaundice Bil 3 ALT ALP

25 Causes of Obstructive Jaundice Gallstones short/painful history Ca Pancreas indolent painless Hx Ultrasound scan

26 Hepatic Jaundice 2 Bil ALT ALP

27 Hepatic Jaundice a 2 b

28 Hepatic Jaundice 2 a

29 2a Acute Hepatitis Short History No signs of CLD Causes Hepatitis A/B EBV CMV Paracetamol overdose Autoimmune Pregnancy

30 Hepatic Jaundice 2 b

31 2b Decompensated cirrhosis Less acute Hx (less acutely ill) Signs of chronic liver disease Causes of cirrhosis

32 Signs of CLD

33 Signs of CLD

34 Signs of CLD

35 Varices

36 Cirrhosis Alcohol Hep B/C Autoimmune hepatitis Haemochromatosis PBC PSC Wilson s Others

37 Cirrhosis Alcohol Hep B/C Autoimmune hepatitis Haemochromatosis PBC PSC Wilson s Others History/γGT Serology AutoAb /ASMA Ferritin/TS AMA/Ig s ANCA Caeruloplasmin TFT s/coeliac Coeliac/α1AT

38 The Liver Aetiology Screen FBC/Ferritin Ferritin/B12/ /B12/Folate/Clotting U&E s/lft s LFT s/tft stft s AutoAb screen ANA/AMA/ASMA Ig s αfp Caeruloplasmin/ α1at HepB/C serology USS size of liver and focal lesions

39 Isolated Transaminitis No Jaundice ALT ALP

40 Isolated raised ALT Most likely fatty liver/alcohol Needs complete liver aetiology screen Check AST/γGT USS Biopsy if ALT > x2normal

41 Isolated Raised ALP Ensure origin ALP isoenzymes γgt USS If of bony origin Ca/Vitamin D/PTHD

42 Medication Any medication can cause an elevation of liver enzymes NSAID s Flucloxacillin Statin Anti-epileptic TB drugs

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44 Mixed Transaminitis ALT/ ALP ratio ALT e.g. X10 normal ALP e.g. X1.5 normal Trends over time

45 Acute liver failure Not to miss

46 Acute Liver failure - Diagnosis Jaundice Encephalopathy ALL 3 Coagulopathy

47 Encephalopathy Grade 1: 1 Mild confusion, slowing of ability to do mental tasks e.g. serial 7 s Grade 2: 2 Drowsiness, inappropriate behaviour Grade 3: 3 Somnolent but rousable, marked confusion Grade 4: 4 Coma

48 Causes of Acute Liver failure Paracetamol overdose Viral: Hepatitis A/B; HSV Acute fatty liver of pregnancy Autoimmune hepatitis Budd-Chiari syndrome Acute Wilson s disease

49 OLT criteria Liver Transplant (paracetamol) Arterial ph <7.30 after rehydration or all three of the following: Prothrombin time >100secs Creatinine >300umols/l Encephalopathy of Grade III or IV

50 OLT criteria Liver Transplant (non paracetamol) Prothrombin time >100secs Or any three of the following: NonA-NonB NonB aetiology Jaundice to encephalopathy time of >7days Age<10 or >40 years Prothrombin time >50 seconds Serum bilirubin >300umols/l

51 Fatty Liver NAFLD Non alcoholic fatty liver disease NASH Non alcoholic steatohepatitis Usually raised ALT But also raised ALP/GGT/Ferritin

52 Fatty Liver Management AASLD 2002

53 Fatty Liver Management 2007 Harrison AH CGH 2 8; 6: 26-9

54 Risk factors for NASH cirrhosis Obesity Age 50 y Non African American ethnicity Female gender Diabetes mellitus, type II Hypertension AST 45 U/L AST/ALT ratio Low platelet count

55 Fatty Liver Future Management Fibrosis markers + Elastography (USS/MRI) Harrison AH CGH 2 8; 6: 26-9

56 Who to refer? Liver failure acute and chronic Any condition that can lead to cirrhosis Any cirrhotic

57 Any Questions? 1 a 2 b 3