Abnormal Liver Test! by! George Vagujhelyi M.D.!
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1 Abnormal Liver Test! by! George Vagujhelyi M.D.! 1!
2 Liver Enzymes! AST asparate aminotransferase! ALT alanine aminotransferase! Alkaline phosphatase! GGT Gamma-glytamyl transpeptidase! 5 -nucleosidase! LDH lactate dehydrogenase!
3 AST: found in hepatocytes, skeletal and cardiac muscle and other organs.! ALT: relatively specific for liver injury! ALP: found in bone, liver and placenta! Prothrombin time:! marker of liver function! factors II,V,VII,and X synthesized in the liver,! factors are dependent on Vit K! Vit K deficiency: antibiotics, prolonged fasting, SB disorder(celiac)! Albumin: prolonged illness, cancer!
4 elevations in liver enzymes reflect damage to the liver or biliary obstruction! abnormal serum albumin or prothrombin time seen in impaired hepatic synthetic function! bilirubin reflects the ability of the liver to detoxify metabolites and transport organ anions into bile!
5 Evaluation! History: this helps identify potential risk factors! Family history! ETOH consumption! >210 gm/wk men, >140gm/wk women 2yrs! Drugs! prescription, OTC, herbal, dietary!
6 Travel! Transfusion prior to 1992! Medical conditions! right sided heart failure! DM,! obesity,! pregnancy,! IBD,! Celiac,! thyroid!
7 Physical exam! Temporal and proximal muscle wasting! spider nevi, palmar erythema, gynecomastia and caput medusae! Ascities! Hepatic encephalopathy! Dupuytrens contractures, testicular atrophy! Right sided pleural effusion! liver and spleen size!
8 Acute! generally less then 3 months! can produce levels more then 1000, ALT>AST! associated with malaise, anorexia, abdominal pain and jaundice! Hepatitis A,: exposure hx! Hepatitis B risk factors! drug induced! alcoholic hepatitis ( AST>ALT,2:1, levels 400)! ischemia, hypotensive event! Wilsons disease!
9 Dx! Actaminophen! Toxicology! Acute hepatitis! IgM anti-hepatitis A! HBsAg and IgM anti-hepatitis B core! HCV RNA! Autoimmune markers(ana,asma)! Ceruloplasmin if <40 yrs usually less the 20mg/dl)! U/S!
10 Chronic! > 3 months of elevated enzymes! 2-5 times ULN! usually asymptomatic, slight fatigue and RUQ pain! Causes! Hepatitis C, B,! NAFLD! hemochromatosis! AIH! Alcoholic liver disease.!
11 Mild Chronic AST/ALT! Medications! Chronic B or C (HBsAg,HBsAb, HB PCR, HCV)! Screen for alcohol abuse (AST/ALT >2:1)! Hemochromatosis(iron studies,ferritin >400?)! NAFLD ( imaging U/S,CT)! AIH! Wilson ( ceruloplasmin,kaiser-fleisher rings, urine copper)! Thyroid! Celiac disease!
12 Mild Chroinc AST/ALT! Medication! Timing!!! Antibiotics, antidepressants, lipid lowering drugs,sulfonamides,salicylates NSAIDS,antiepileptics anti TB! OTC!
13 Mild Chronic AST/ALT! Viral hepatitis! Exposure history! Travel! Serology studies! HBsAg,HBsAb,Hepatitis B core,hcv!
14 Hereditary Hemochromatosis! common disorder 1: white persons are homozygous! 1:10 are heterozygous! Family history! Screening! serum Fe and TIBC get a transferrin saturation >45%! Ferritin >400 (acute phased reactant)! dx with genetic testing/liver biopsy!
15 Mild Chronic AST/ALT! Fatty Liver/NAFLD! it is a hepatic manifestation of! metabolic syndrome! obesity! type 2 DM! hyperlipidemia! Dx! U/S! CT!
16 Mild Chronic AST/ALT! Who to observe! general approach to a first-time increase in LFT s! asymptomatic, incidental finding! rule out! risk factors! LFT s less then 2 time normal! liver function is preserved! it is reasonable to observe but if there is a change then further evaluation is required.!
17 Jaundice! Bilirubin greater then 2.5 mg/dl! determine whether it is conjugated vs unconjugated.! common unconjugated disorder is Gilbert syndrome! total bilirubin is about 3 mg/dl, direct bilirubin is about 0.3mg/dl! under periods of stress,illness, fasting an isolated elevated Tbil with normal, LFT s and Hgb.! Obstructive! abdominal pain, fever, palpable GB! Non obstructive! hepatocellular dysfunction!
18 Isolated Hyperbilirubinemia unconjugated! Increased bilirubin production! Hemolysis! Hemotoma! Impaired hepatic uptake! heart failure! Portosystemic shunts! drugs- rifampin and probenecid! Impaired bilirubin conjugation! Gilberts! Thyroidism!
19 Hyperbilirubinemia conjugated! Extrahepatic! CBD stones! PSC! Acute and Chronic Pancreatitis! Intrahepatic! viral hepatitis! alcoholic hepatitis! NASH! cirrhosis! Drugs! Sepsis! TPN! infiltrative diseases!
20 !! aline!! Alkaline phosphatase!!!!! Determine if an isolate ALP is from the liver check a GGT.! ALP can also be fractionated to see if coming from the bone, liver or placenta.! If isolated but coming from the liver think of! chronic cholestatis( partial biliary obstruction, PBC,PSC)! infiltrative process( amyloidosis,sacroidosis, cancer)! may have normal bilirubin! DX! U/S, ERCP,MRCP and CT! intrahepatic causes; (if imaging studies normal)! AMA, drug hx, liver biopsy?!
21 Cholestatic disorders! disease! clue! dx! PBC! middle age female! AMA! PSC! UC! MRCP,ERCP! Large bile duct! drug induced! infiltrative! jaundice and pain! meds and timing! amyloid,! sarcoid! U/S,ERCP MRCP! w/drawal! CT, US! inflammatory! inflammation! bd cultures!
22 Questions!
23 A 60 yr old man is brought to the ER, by his wife who admits that the patient has a drinking problem and has been complaining of back pain for several days.! PE : spider nevi and palmar erythema, liver edge is firm and spleen is palpable.! labs: Hgb 11.9, PLT 130 AST 4200 ALT 5100, total bili 3.1mg/dl ALP 70 U/L, INR 1.6! whats the most likely cause! pancreatic cancer! Acute hep A! Acetaminophen toxicity! ischemic hepatitis! Alcoholic hepatitis!
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