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Abnormal liver function tests R

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At lease two large studies suggested that the cutoff values should be adjusted ... Hx (for example) Arthralgias and myalgias predating jaundice ... – PowerPoint PPT presentation

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Title: Abnormal liver function tests R


1
Abnormal liver function tests R ???
  • UpToDate
  • Last literature review version 16.1 ?? 2008   
  • This topic last updated ??? 13, 2007

2
EPIDEMIOLOGY
  • The sensitivity and specificity of the serum
    aminotransferases (particularly serum ALT) for
    discriminating those with and without liver
    disease depends upon the cutoff values chosen to
    define an abnormal test.
  • At lease two large studies suggested that the
    cutoff values should be adjusted for gender and
    body mass index.

3
How to approach
  • History (Hx)
  • Physical examination (PE)
  • Laboratory testing (Lab) 

4
Hx
  • The use of or exposure to any chemical or
    medication (including herbal therapies)
  • The duration of LFT abnormalities
  • The presence of any accompanying symptoms
  • Jaundice
  • Arthralgias, myalgias
  • Rash
  • Anorexia, weight loss
  • Abdominal pain
  • Fever
  • Pruritus
  • Changes in the urine and stool

5
Hx
  • Possible parenteral exposures
  • Transfusions
  • Intravenous and intranasal drug use
  • Tattoos
  • Sexual activity
  • Recent travel history
  • Exposure to people with jaundice
  • Exposure to possibly contaminated foods
  • Occupational exposure to hepatotoxins
  • Alcohol consumption

6
Hx (for example)
  • Arthralgias and myalgias predating jaundice
  • Favor viral or drug-related hepatitis
  • Jaundice associated with the sudden onset of
    severe right upper quadrant pain and shaking
    chills
  • Favor choledocholithiasis and ascending
    cholangitis
  • Bra…bra…

7
PE
  • Longstanding diseases
  • temporal and proximal muscle wasting
  • Stigmata of chronic liver disease
  • spider nevi
  • palmar erythema
  • gynecomastia
  • caput medusae
  • Laennec's cirrhosis and occasionally in other
    types of cirrhosis
  • Dupuytren's contractures
  • parotid gland enlargement
  • testicular atrophy

8
PE
  • Abdominal malignancy
  • An enlarged left supraclavicular node (Virchow's
    node)
  • Periumbilical nodule (Sister Mary Joseph's
    nodule)
  • Hepatic congestion
  • Jugular venous distension, a sign of right sided
    heart failure
  • Advanced cirrhosis
  • A right pleural effusion, in the absence of
    clinically apparent ascites

9
(No Transcript)
10
PE
  • Size and consistency of the liver
  • Size of the spleen
  • Ascites (fluid wave or shifting dullness)
  • An enlarged tender liver
  • viral or alcoholic hepatitis
  • acutely congested liver secondary to right-sided
    heart failure (less)

11
Lab
  • Alk-P
  • disproportionate elevation in cholestatic process
    than serum aminotransferases (opposed for
    hepatocellular injury)
  • Albumin
  • Low cirrhosis or cancer
  • Normal viral hepatitis or choledocholithiasis
  • PT
  • vitamin K deficiency
  • significant hepatocellular dysfunction
  • Bilirubin in the urine
  • Hyperbilirubinemia
  • conjugated bilirubin
  • unconjugated bilirubin
  • Early sign of liver disease

12
Mild Chronic Elevation in Serum Aminotransferases
  • Step one 
  • Medications and supplements
  • Alcohol use
  • Viral hepatitis B and C
  • Hemochromatosis
  • Fatty liver (hepatic steatosis and
    steatohepatitis  )

13
Mild Chronic Elevation in Serum Aminotransferases
  • Step two
  • Muscle disorders
  • Thyroid disease
  • Celiac disease (less)
  • Adrenal insufficiency (less)
  • Anorexia nervosa (less)

14
Mild Chronic Elevation in Serum Aminotransferases
  • Step three 
  • Autoimmune hepatitis
  • Wilson's disease 
  • Alpha-1-antitrypsin deficiency 

15
Mild Chronic Elevation in Serum Aminotransferases
  • Step four 
  • A liver biopsy is often considered in patients in
    whom all of the above testing has been
    unyielding.
  • However, in some settings, the best course may be
    observation.

16
Predominantly hepatocellular pattern with
jaundice 
17
Alcoholic hepatitis 
  • ASTALT ratio of at least 21
  • AST rarely exceeds 300 U/L

18
Viral hepatitis 
  • Hepatitis A IgM antibody
  • Hepatitis B surface antigen
  • Hepatitis B core IgM antibody
  • Hepatitis C viral RNA
  • acute (aminotransferases greater than 500 U/L
    with the ALT greater than or equal to the AST )
  • hepatitis C is an uncommon cause of acute viral
    hepatitis

19
Toxic hepatitis 
  • Predictable drug reactions
  • dose-dependent
  • affect all patients
  • Ex acetaminophen
  • UnPredictable drug reactions
  • any drug can cause an idiosyncratic reaction
  • Environmental toxins
  • vinyl chloride, herbal preparations
  • mushrooms Amanita phalloides or verna

20
Shock liver (ischemic hepatitis)
  • prolonged period of systemic hypotension (such as
    following a cardiac arrest or patients with
    severe heart failure)
  • exceeding 1000 IU/L or 50 times the upper limit
    of normal
  • concomitant deterioration of renal function

21
Wilson's disease 
  • younger than 40 y/o
  • concomitant hemolytic anemia

22
Predominantly cholestatic pattern 
  • First step obtain a right upper quadrant
    ultrasound

23
Extrahepatic cholestasis 
  • Presence of biliary dilatation
  • Choledocholithiasis
  • CT (head of the pancreas)
  • ERCP (ampulla of Vater)
  • Gold standard
  • removal of common bile duct stones and the
    placement of stents
  • Transhepatic cholangiography
  • MRCP
  • Malignant causes
  • primary sclerosing cholangitis
  • Chronic pancreatitis uncommonly
  • AIDS cholangiopathy

24
Intrahepatic cholestasis 
  • Absence of biliary dilatation
  • False negative (scarring prevent from)
  • partial obstruction of the common bile duct
  • cirrhosis
  • primary sclerosing cholangitis
  • Drug
  • Primary biliary cirrhosis
  • Primary sclerosing cholangitis (in 65 percent of
    patients with PSC, both intra- and extrahepatic
    ducts are involved )
  • Other total parenteral nutrition,
    non-hepatobiliary sepsis, benign post-operative
    cholestasis, and a paraneoplastic syndrome dot to
    different malignancies

25
Thank you for your attention
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