Abnormal LFTs

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Abnormal LFTs

• University California San Francisco
• Family Medicine Residency Program
• Megan R. Mahoney, M.D.

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Quick True or False

• In asymptomatic patient with negative serum
  testing and mild transaminase elevations, a
  period of lifestyle modification can be tried.
• If abnormalities persist at the six-month
  follow-up visit, a CT of the liver is the
  recommend imaging modality.
• Annual screening of health, asymptomatic patients
  for liver disease using ALT and AST levels is not
  useful.
• The AST/ALT ratio is not helpful in diagnosis.
• Strenuous exercise or myopathy cannot cause AST
  elevations in asymptomatic patients.
• Hyperthyroidism has not been found to affect
  serum levels of ALT and AST.
• Of the two, AST is thought to be more specific
  for hepatic injury because it is present mainly
  in the cytosol of the liver and in low
  concentrations elsewhere.

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Multiple Choice Questions

• AST is present in cytosol and mitochondria of
• a) the liver
• b) heart
• c) skeletal muscle
• d) kidneys
• e) brain
• f) pancreas
• g) lungs
• h) a) and c)
• i) all of the above

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Multiple Choice Questions

• The following health conditions can cause or
  augment liver transaminase elevations
• a) diabetes
• b) heart disease (including congestive heart
  failure)
• c) thyroid disease
• d) muscle disease
• e) cancer
• f) b), c), and d)
• g) all of the above

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Case 1

• PH is a 25 y.o. woman presenting the morning
  after a long night of partying. She feels
  flu-like symptoms, no jaundice, no
  nausea/vomiting, or abd pain. She also endorsed
  an one-year h/o palpitations.

Meds Acetaminophen Nitrofurantoin Trazadone Sept
ra Herbal supplements Ephedra Kava Shark
cartilage
HRB 3 Kir Royals 2 Sex on the Beachs 5 bumps
of cocaine last night
All NKDA PMH history of sharing botox needles
with questionable friends
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Case 1
PE VS nl Gen glamorous-looking HEENT no
scleral icterus CV nl Abd mild RUQ tenderness
no Murphys Skin no jaundice Labs AST 213
ALT 115 Alk Phos 150 Tbili 1.0 Alb 4 CBC nl
TSH 0.4 Hepatitis A and B serologies negative
Hepatitis C pending In 6 months PE
unchanged Labs AST 65 ALT 55 Alk Phos 120 Tbili
0.9 Alb 4.2 TSH 0.5 T4 nl
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Ratio of LFTs

• The ratio of AST to ALT has some clinical
  utility, but has important limitations.
• In many forms of acute and chronic liver injury
  or steatosis (fatty infiltration of the liver),
  the ratio is less than or equal to 1. This is
  particularly true in patients with hepatitis C.
• However, an AST/ALT ratio greater than 2
  characteristically is present in alcoholic
  hepatitis.

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Bottom Line Tx HBV and HCV

• HCV
• PEG-IFN alpha-2a RBV
• Predictors of response
• Genotype 2/3
• Female
• Age lt 40
• Low VL lt 2X106
• No fibrosis
• No alcohol
• HIV ()
• BMI low

• HBV
• Nucleos(t)ide analogs (entecavir)
• Interferon
• HBV is never cured but controlled
• Immune seroconversion

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Case 2

• KW is a 28 yo man who wants a complete history
  and physical, willing to pay out-of-pocket. Even
  after discussing with him the lack of evidence
  for screening liver enzymes, he still desires the
  tests. He is here for an interpretation.
• Labs
• AST 45 ALT 70
• Alk Phos 150 Tbili 1.0 Alb 3.4
• PT/PTT/INR nl
• CBC nl
• What tests should be ordered?

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Case 2

• Serum Fe and TIBG nl
• Viral Hepatitis serologies negative
• Labs 6 months later
• AST 54 ALT 85
• Alk Phos 112 Tbili 10.8 Alb 3.5
• What should be done now?
• U/S diffuse fatty infiltrate no lesions no
  scarring
• What should be done now?

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Bottom Line Tx NASH

• Steatohepatitis (or nonalcoholic fatty liver
  disease) often is discovered by imaging.
• This condition may be the most frequent cause of
  mild liver chemistry elevations and is especially
  common in patients who are obese, and those who
  have diabetes or hyperlipidemia.
• Lifestyle modifications is the mainstay of
  therapy.

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Case 3

• WD is a 12 yo girl referred from her
  ophthamologist. Here for work-up.

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Kayser-Fleischer ring

• The Kayser-Fleischer ring is a gold or gray-brown
  opacity in the peripheral cornea.
• It first develops superiorly in the cornea (12
  o'clock), then inferiorly, and finally in the
  horizontal meridian. It represents a deposit of
  copper and sulfur-rich granules in Descemet's
  membrane, and is reversible with treatment.
• Additional later ocular findings in Wilson
  disease include sunflower cataracts, saccadic
  pursuit movements, loss of accommodation
  response, and apraxia of opening the eyelid.