Abnormal Liver Tests - PowerPoint PPT Presentation

Loading...

PPT – Abnormal Liver Tests PowerPoint presentation | free to download - id: 4051c4-NGY0N



Loading


The Adobe Flash plugin is needed to view this content

Get the plugin now

View by Category
About This Presentation
Title:

Abnormal Liver Tests

Description:

Abnormal Liver Tests Harry Colt, MD 9/4/07 Goal Objectives Why is this important? one of the common problems in everyday clinical practice sorting out the cause, can ... – PowerPoint PPT presentation

Number of Views:49
Avg rating:3.0/5.0
Slides: 54
Provided by: maineG3
Learn more at: http://www.mdfpcases.org
Category:
Tags: abnormal | liver | tests

less

Write a Comment
User Comments (0)
Transcript and Presenter's Notes

Title: Abnormal Liver Tests


1
Abnormal Liver Tests
  • Harry Colt, MD
  • 9/4/07

2
Goal
At the conclusion of this session, participants
will be able to initiate appropriate evaluation
and management of abnormal liver tests.
3
Objectives
  • Participants will be able to
  • recognize common patterns of abnormal liver
    tests
  • list the common causes of hepatocellular injury
  • list the common causes of cholestatic disease
  • initiate further workup of abnormal liver tests.

4
Why is this important?
  • one of the common problems in everyday clinical
    practice
  • sorting out the cause, can initially seem
    puzzling
  • knowledge of the pathophysiology of the enzymes
    and patterns of abnormalities are helpful

5
Case 1 62 yo man with hypertension, obesity
and hyperlipidemia has a CMP which is normal
except for AST194, ALT132. What do you want to
know and/or do?
6
Evaluation of Abnormal liver test includes
  • history
  • physical
  • analysis of enzyme pattern
  • 1. hepatocellular or cholestatic
  • 2. magnitude of abnormality
  • 3. rate of change
  • further testing

7
History
  • HPI
  • anorexia, nausea, vomiting, fatigue
  • jaundice, pruritus, clay colored stools, dark
    urine

8
History (contd)
  • PMH
  • alcohol use
  • medication list
  • OTC meds, illicit meds, herbal remedies
  • blood transfusions
  • sexual history
  • occupational history
  • raw oysters, clams, etc.
  • Family history (Gilberts, Wilsons,
    hemochromatosis, alpha one antitrypsin deficiency

9
Physical
  • jaundice, hepatomegaly, ascites, RUQ tenderness,
    palmar erythema, spider nevi, asterixis,
    encephalopathy

10
Pattern of Liver Enzyme Elevation
  • Hepatocellular or cholestatic?
  • Magnitude of change?
  • Rate of change?

11
Hepatocellular (aminotransferases)
  • not liver function tests
  • sensitive indicators of liver cell injury
  • released when liver cell membrane damaged
  • AST found in liver, cardiac muscle, skeletal
    muscles, kidneys, brain, pancreas
  • ALT found in liver, skeletal muscle

12
Degree of Elevation Important!
13
Causes of Hepatocellular Pattern
  • alcohol induced liver injury
  • medications (prescriptions, OTC, drugs, herbs
  • chronic Hepatitis B
  • chronic Hepatitis C
  • autoimmune
  • hepatic steatosis (fatty liver)
  • hemochromatosis
  • Wilsons disease
  • alpha-one antitrypsin deficiency
  • celiac disease

14
Non-Liver Causes of Hepatocellular Pattern
  • inherited disorders of muscle metabolism
  • Acquired muscle disease
  • strenuous exercise

15
Case 1 62 yo man with hypertension, obesity
and hyperlipidemia has a CMP which is normal
except for AST194, ALT132. What tests do you
want to order?
16
Initial Tests (Hepatocellular)
  • Hep C antibody
  • Hep B Sag (Hep B SAb, Hep B Cab)
  • Fe, TIBC
  • SPEP
  • increased polyclonal immunoglobulins suggest
    autoimmune hepatitis
  • low alpha one globulin suggests alpha one
    antitrypsin deficiency
  • --------------------------------------------------
    ---------
  • Ceruloplasmin (lt40 yo)

17
Additional Tests (Hepatocellular)
  • PCR for Hep C RNA
  • alpha one antitrypsin phenotyping
  • antiendomysial and antigliadin Ab
  • ultrasound
  • liver biopsy

18
Alcoholic Liver Disease
  • ASTgt ALT (at least 21)
  • if AST twice ALT, 90 have alcoholic liver
    disease
  • if AST 3x ALT, 96 have alcoholic liver disease
  • only rarely in alcoholic liver disease is AST
    gt8x normal or ALT gt5x normal

19
(No Transcript)
20
(No Transcript)
21
Hepatitis C
  • 4 million Americans Hep C antibody positive
  • 3 million chronically infected (Hep C virus RNA
    present)
  • risk factors blood transfusions, IV drug use,
    tattoos/body piercing, high risk sexual activity,
    work duties
  • initial test Hep C Ab (92-97 sensitivity)
  • if positive, confirm with PCR for Hep C virus
    RNA
  • if positive for RNA, consider liver biopsy
  • if Hep C and fibrosis, usually treat

22
Hep B
  • tests Hep B Sag, Hep B SAb, Hep B Cab
  • Hep B Sag positive,
    Hep B Cab positive Hep B
  • Hep B SAb positive,
    Hep B Cab positive immune to Hep B
  • if Hep B Sag positive, do Hep B e antigen and
    Hep B virus DNA
  • if Hep B virus DNA and Hep e antigen present,
    consider liver biopsy and treatment

23
Autoimmune Hepatitis
  • primarily young to middle aged women
  • ?? 41
  • 80 of those with autoimmune hepatitis have
    hypergammaglobulinemia on SPEP
  • liver biopsy is necessary for diagnosis
  • important amenable to treatment

24
Hepatic Steatosis and Nonalcoholic Steatohepatitis
  • usually only mild elevation of aminotransferases
  • ASTALT usually less than 11
  • ultrasound or CT can identify this
  • diagnosis of nonalcoholic steatohepatitis
    requires liver biopsy
  • steatosis has benign course
  • nonalcoholic steatohepatitis can progress to
    cirrhosis
  • weight loss is key to treatment

25
Hemochromatosis
  • common genetic disorder, autosomal recessive
    homozygote frequency 1300
  • excessive GI absorption of iron, and subsequent
    iron deposition in heart, lung, skin
  • screening test Fe, TIBC
  • if Fe/TIBC gt45, consider hemochromatosis
  • if abnormal, liver biopsy
  • important to diagnose for both individual and
    family

26
Wilsons Disease
  • Rare genetic disorder (130,000-1300,000) of
    biliary copper excretion
  • Usually onset before age 25, but consider up to
    age 40
  • Suspect if psych/neuro problems
  • Screen with ceruloplasmin, reduced in 85
  • Also diagnosed by Kayser-Fleischer rings
  • 24 hour urine for copper excretion excretion of
    gt100?g suggests Wilsons
  • Confirm by liver biopsy

27
Alpha-one Antitrypsin Deficiency
  • 11600-12800, suspect if pulmonary disease
  • Screen by diminished alpha globulin on SPEP or
    direct measurement of alpha-one antitrypsin
  • Confirm by phenotype determination

28
Non-Hepatic Causes
  • If other causes ruled out, consider celiac sprue
  • Test for antigliadin or antiendomysial antibodies
  • Acquired and congenital muscle disorders and
    strenuous exercise can cause elevated
    hepatocellular enzymes
  • if muscle disorder suspected, check CPK and
    aldolase which should be elevated

29
If ALT AST elevated, but all other blood tests
normal?
  • If AST, ALT lt2x normal, observe
  • If AST, ALT gt2x normal, biopsy

30
Case 62 yo man with hypertension, obesity,
hyperlipidemia has CMP notable for AST 194, ALT
132. What would you do?
31
Answer History (alcohol, meds, risk factors for
hepatitis, family history, etc.) Physical Analyz
e pattern Hepatocellular Repeat enzymes (off
ETOH) if remain elevated, further workup
32
Further eval includes Hep C antibody Hep B
SAg Fe, TIBC SPEP
33
Further eval includes stop med(s) ultrasound e
tc.
34
Case 2 42 yo woman with hypertension has CMP
which is notable for alkaline phosphatase of
320. What do you do next?
35
  • History (abd pain, jaundice, pruritis, etc.
  • Physical
  • Evaluate pattern of enzymes
  • 1. hepatocellular or cholestatic
  • 2. magnitude of abnormality
  • 3. rate of change
  • Further testing

36
Causes of Elevated Alk Phos
  • Alk phos can come from liver, bone, placenta,
    intestine (rare)
  • Alk phos higher in children, pregnant women
  • First goal is to identify the source (liver vs
    bone)
  • Methods
  • 1. Alk phos fractionation
  • 2. GGT

37
Causes of Elevated Alk Phos
  • If liver source established, suspect cholestasis
    or infiltrative liver disease
  • Causes include partial obstrction of bile ducts,
    primary biliary cirrhosis, sclerosing
    cholangitis, certain drugs (eg, steroids),
    sarcoidosis, granulomatous disease, metastatic
    cancer

38
How to distinguish these entities?
  • Next step
  • ultrasound
  • antimitochondrial antibodies (suggestive of
    primary biliary cirrhosis)

39
  • If antimitochondial antibodies positive, consider
    liver biopsy for primary biliary cirrhosis
  • If biliary dilatation or choledocholithiasis,
    consider ERCP
  • If US and antimitochondrial antibodies negative,
    and Alk phos significantly elevated (gt50),
    consider liver biopsy
  • If US and antimochondrial antibodies negative,
    and Alk phos lt50 elevated, observe

40
Other Liver Tests
  • GGT
  • Very sensitive for hepatobiliary disease, but low
    specificity
  • Fallen out of favor except as confirmatory test
  • BILIRUBIN
  • Unconjugated huperbilirubinemia caused by
    increased bilirubin production or decreased
    hepatic uptake
  • Most common causes of unconjugated
    hyperbilirubinemia Gilberts (5), hemolysis

41
Tests of Liver Function
  • Albumin synthesized by liver
  • Nonspecific. Decreased in advanced stage liver
    disease, malnutrition, nephrotic syndrome
  • Albumin has 20 day half life, so if due to liver,
    it indicates at least several weeks of liver
    disease

42
Tests for Liver Function (contd)
  • 2. INR
  • Prolonged by end stage liver disease, warfarin,
    vitamin K deficiency
  • INR dependant on clotting factors which have half
    life of one day
  • More sensitive indicator of liver synthetic
    function

43
Questions?
44
Cases
45
Case 3 A 36 yo man seeks medical attention
because of anorexia, nausea, and vomiting of 5
days duration. Has low grade fever, and pain in
RUQ of abdomen. What else do you want to know?
46
History Pertinent history includes longstanding
alcohol abuse, consumption of raw oysters during
a recent vacation, and taking 2 g acetaminophen
for back pain daily
47
Case 3 Liver tests show bilrubin 4.8 ALT
950 (18x normal) AST 700 (12x normal) Alk
Phos 480 (2-3x normal) What is the most likely
cause? What would you do next?
48
Questions?
49
Case 4 A 72 yo man with alcoholic
cardiomyopathy is admitted for heart failure.
Medications include captopril and furosemide
which were started 2 weeks earlier. On admission,
bilirubin is 3.0, Alk phos 600, AST 9,200, ALT
6,000. What else do you want to know? What is the
most likely cause for his elevated LFTs?
50
His captopril and furosemide are discontinued,
and 3 days later his liver tests show bilirubin
3.8, Alk Phos 320, AST 400. What is most likely?
51
Case 5 A 48 yo man with arthritis and Hilar
adenopathy comes in for a low grade fever. Liver
tests are bilirubin 0.8, Alk Phos 2,200, AST 88,
ALT 72. What would you do next? What is the most
likely cause?
52
Case 6 72 yo woman with diabetes,HTN, CHF,
hyperlipidemia, obesity, and remote h/o alcohol
abuse. Meds include metformin, lovastatin,
enalapril, propranolol, and ASA. LFTs on CMP show
AST 340, ALT 100, Alk phos 150, TB 0.8 What is
your differential? What is most likely?
53
Resources
  1. Giannini E, et al. Liver Enzyme Alteration A
    Guide for Clinicians. CMAJ 2005172(3)367-79.
  2. Pratt D, Kaplan M. Evaluation of Abnormal
    Liver-Enzyme Results in Asymptomatic Patients.
    NEJM 2000342(17)1266-71.
About PowerShow.com