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Evaluation of Abnormal Liver Function Tests

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Evaluation of Abnormal Liver Function Tests Dr Deb Datta Consultant Gastroenterolgist Overview Background Elevated Transaminases Isolated Hyperbilirubinaemia Elevated ... – PowerPoint PPT presentation

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Title: Evaluation of Abnormal Liver Function Tests


1
Evaluation of Abnormal Liver Function Tests
  • Dr Deb Datta
  • Consultant Gastroenterolgist

2
Overview
  • Background
  • Elevated Transaminases
  • Isolated Hyperbilirubinaemia
  • Elevated Alkaline phosphatase
  • Mixed Picture
  • Case History

3
Background
  • Liver function tests ordered routinely
  • 1-4 of asymptomatic patients have abnormal
    values
  • Population based survey-8.9 raised ALT
  • OBESITY
  • Serious underlying disease uncommon
  • Diagnosis often reached non invasively
  • No consensus on cost effective approach

4
HISTORY
  • Duration of abnormaL LFT
  • Symptoms- Jaundice, arthralgia, pain, pruritus,
    weight loss
  • Medication (Herbal)
  • Travel History
  • Transfusion
  • IV drug abuse
  • ALCOHOL

5
EXAMINATION
  • Stigmata of chronic liver disease
  • Lympadenopathy
  • Periumbilical nodule
  • Palpable mass

6
Transaminases
  • May not be elevated in chronic liver disease
  • HCV
  • Cirrhosis
  • Minimal ALT elevations (lt1.5 X normal)
  • Race/Gender
  • Obesity
  • Muscle injury

7
Elevation in Serum Transaminases
  • STEP 1
  • Medications, herbal treatment, drugs
  • Screen for alcohol abuse (AST/ALTgt21)
  • Obtain serology for Hepatitis B C
  • Screen for Haemochromatosis (TIBCgt45)
  • USG (?Fatty Liver)

8
Elevation in Serum Transaminases
  • STEP 2
  • Consider Autoimmune liver disease
  • Wilsons Disease (lt40)
  • Alpha 1 antitrypsin Deficiency (Emphysema)

9
Elevation in Serum Transaminases
  • STEP 3
  • Exclude muscle disorder (CK)
  • Check TFT
  • ?Coeliac (Fe def)
  • Adrenal insufficiency
  • STEP 4
  • Liver Biopsy ? When

10
Elevated AST ALT, lt4X normal
Hx physical stop hepatotoxic meds
Serologies HAV IgM HBsAg HBcIgM HCV Ab or
RNA
LFTs, PT, albumin, CBC, Hep A/B/C, Fe, TIBC,
Ferritin
Positive serology
Negative serology
Negative serology, asymptomatic
11
Negative Serology- Asymptomatic
Stop EtOH meds wt loss glucose control
6 months
Repeat LFTs
Abnormal
Normal
Observation
Ultrasound, ANA, smooth muscle Ab, ceruloplasmin,
antitrypsin, gliadin endomysial Ab
Liver biopsy
?
12
Negative Serology- Clinical Signs/Symptoms of
Liver Disease
Consider ultrasound, ANA, smooth muscle Ab,
ceruloplasmin, antitrypsin
Abnormal
Liver biopsy
?
13
Isolated Hyperbilirubinemia
  • Product of hemoglobin breakdown
  • Unconjugated (indirect)- insoluble
  • Haemolysis (Reticulocyte count)
  • Gilberts syndrome (3-7 population)

14
Alkaline Phosphatase
  • Produced by biliary epithelial cells
  • Non-specific to liver bone, intestine, placenta
  • Elevations
  • Biliary duct obstruction
  • Primary biliary cirrhosis
  • Primary sclerosing cholangitis
  • Infiltrative liver disease- ie sarcoid, lymphoma
  • Hepatitis/cirrhosis
  • Medications

15
Elevated Serum alkaline phoaphatase
16
ALP Hepatobiliary origin
17
MIXED PICTURE
  • Hepatocellular pattern with Jaundice
  • Alcoholic hepatitis
  • Viral Hepatitis (A E)
  • Toxic hepatitis (Paracetamol, Wild mushroom)
  • Autoimmune
  • Wilsons

18
MIXED PICTURE
  • CHOLESTATIC PICTURE
  • USG
  • Extrahepatic
  • Choledocholithiasis
  • Pancreatic cancer
  • Cholangiocarcinoma
  • PSC
  • Intrahepatic
  • (Drug induced,PBC,PSC,Pregnancy)

19
Other Liver Labs
  • Albumin
  • decreased by trauma, inflammatory conditions,
    malnutrition
  • Prothrombin time (PT)
  • -no change until liver loses 80 capacity
  • Ammonia
  • No correlation between brain serum values
  • Related to encephalopathy

20
Summary
  • Algorithms based on poor quality or absence of
    evidence
  • Most asymptomatic patients can safely be followed
    for a period of time to see if abnormalities
    resolve
  • If lab abnormalities persist be thoughtful with
    ordering

21
48 yr male lawyer
  • Dyspepsia
  • HP negative
  • PPI -4 weeks
  • No better Right hypochondrial discomfort
  • DM Type 2 (Diet), Simvastatin (CH -5.8)
  • Weight 93.5 Kg
  • Alcohol - rare

22
48 yr male lawyer
  • USG and new PPI
  • Increased echogenicity- fatty liver
  • ALT-78
  • Asymptomatic but very anxious
  • Hepatitis serology negative f/up 3 months
  • ALT-92 Cholesterol -6.4 Glucose-8
  • WHAT NOW?

23
  • Stop statin and repeat blood in 3 months
  • Continue statin and repeat blood in 3 months
  • Strict diet, exercise programme and monitor
  • Liver biopsy
  • Do nothing go away !!!

24
Nonalcoholic steatohepatitis
  • No significant alcohol but liver biopsy similar
    to alcoholic steatohepatitis
  • No hepatitis B or C
  • Central obesity, type 2 DM, Dyslipidemia-
    Metabolic syndrome
  • Men 20-40 of population
  • ?Insulin resistance /?oxidative injury

25
Nonalcoholic steatohepatitis
  • Stable condition- compared to ALD
  • Asymptomatic- ?fatigue
  • Role of liver biopsy - prognosis
  • 8-26 histological progression- linked with
    obesity, liver biopsy balloon degeneration,
    Mallory hyaline
  • Cirrhosis 3-15( gt45,0besity,DM)

26
Treatment
  • Weight reduction- gradual
  • Diabetic and Lipid control
  • Vitamin E Vitamin C
  • Metformin
  • Rosiglitazone
  • Pentoxifylline

27
Mallory bodies
28
NASH
29
THANK YOU
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