CLINICAL APPROACH TO THE PATIENT WITH ABNORMAL LIVER TEST RESULTS DAVID E. KATZ, MD PGY3 WRAMC DOM I

1
CLINICAL APPROACH TO THE PATIENT WITH ABNORMAL
LIVER TEST RESULTSDAVID E. KATZ, MDPGY-3WRAMC
DOMINTERN LECTURE SERIES 98
2

• OBSTRUCTION
• INFLAMMATION
• SYNTHETIC ABILITY
• DETOXIFICATION
• PORTAL HYPERTENSION

3

• OBSTRUCTION

4

• OBSTRUCTION TBIL, DBIL, ALK-P

5

• INFLAMMATORY

6

• INFLAMMATORY AST, ALT, GGT

7

• SYNTHETIC ABILITY

8

• SYNTHETIC ABILITY ALBUMEN, PT, FACTOR LEVELS,
  GLYCEMIC CONTROL.

9

• DETOXIFICATION

10

• DETOXIFICTION NH3, MS CHANGES

11

• PORTAL HYPERTENSION

12

• PORTAL HYPERTENSION PLATELETS, WBC,
  SPLENOMEGALY, VARICES

13

• LIVER FUNCTION TEST
• GALACTOSE CLEARANCE
• AMINOPYRINE CLEARANCE TEST
• INCIDENCE OF CLINICALLY SIGNIFICANT LIVER
  DISEASE 1

14
CLINICAL ASSESSMENT OF THE PATIENT

• HEPATOCELLULAR NECROSIS/VIRAL HEPATITIS
  ANOREXIA/N/V/F.
• CHOLESTASIS/INAD. BILE FLOW DEEP JAUNDICE,
  PRURITIS, CLAY COLORED STOOLS, DARK URINE.
• CHOLESTASIS INTRAHEPATIC/EXTRAHEPATIC (COLIC,
  FEVER, CHILLS-STONES/ T)

15
FAMILY HISTORY

• INDIRECT HYPERBIL- HEMOLYSIS OR GILBERTS
  SYNDROME.
• DIRECT HYPERBIL- DUBIN-JOHNSON
• HX OF SEVERE LIVER DZ WILSONS DZ,
  HEMOCHROMATOSIS, ALPHA-1-AT

16
HISTORY

• SEXUAL HISTORY, TRAVEL, ETOH, DRUGS, ?BLOOD
  TRANSFUSION, ?NEEDLE STICKS, RAW OYSTERS
• HEMATOLOGIC DISEASE
• CARDIAC DZ/IBD/DIABETES/SKIN PIGMENTATION/CARDIAC
  DZ/ARTHRITIS/HYPOGONADISM/ THYROID DISEASE.

17
PHYSICAL EXAM

• GO
• NUTS!!!!

18
PHYSICAL EXAM

• PALPABLE GB- EXTRAHEPATIC CHOLESTASIS
• BRUIT- ANUERYSM/TR
• KAYSER-FLEISCHER RINGS WILSONS DZ
• MURPHY SIGN ACUTE CHOLECYSTITIS

19
BILIRUBIN

• TBIL
• UNCONGUGATED HEMOLYSIS/GILBERTS (TBIL
• CONJUGATED HEPATOCELLULAR DYSFUNCTION OR
  CHOLESTASIS
• CBD OBS STONES15 (30, EXTRAHEPATIC OBSTR
  UNLIKELY)

20
TRANSAMINASES

• ENZYMES INVOLVED IN THE TRANSFER OF AMINO GROUPS
  OF ASPARTATE AND ALANINE TO KETOGLUTARIC ACID.

21
TRANSAMINASES

• AST GLUTAMIC-OXALOACETIC TRANSAMINASE
• CARDIAC
• SKELETAL
• KIDNEY
• BRAIN
• LIVER

22
TRANSAMINASE

• ALT GLUTAMATE PYRUVATE TRANSAMINASE
• ALMOST EXCLUSIVELY IN LIVER
• AST W/O ALT
• CARDIAC DZ
• MACRO-AST

23
AST/ALT RATIO

• AST BOTH CYTOSOL AND MITO
• ALT CYTOSOL
• ETOH DAMAGE TO MITOCHONDRIA
• ETOH LIVER DZ/PYRIDOXINE DEF
• AST NOT 250 U/L
• RATIO LESS USEFUL IN CHRONIC LIVER DZ
• VIRAL DZ ALTAST

24
TRANSAMINASES

• CHOLEDOCHOLITHIASIS AST EARLIEST ABNORMALITY,
  TRANSIENT
• DRUG/VIRAL RISE TO LOW 1000S IN 1-2 WEEKS.
• ISCHEMIC HEPATITIS ACUTE INCREASE (10K IU/L)
  RETURN WITHIN A WEEK

25
TRANSAMINASES

• 10,000 IU/L ACETAMINOPHEN AND IN HERPES SIMPLEX
  VIRUS.
• MEDS THAT INC AST

26
MEDS

• ACET/ NSAIDS
• ACEI
• NICOTINIC ACID
• ABX INH, SULFA, E-MYCIN
• ANTIFUNGAL GRISEOFULVIN/FLUCONAZOLE

27
TRANSAMINITIS

• NASH
• THYROID DZ

28
ALKALINE PHOSPHATASE

• FAMILY OF ENZYMES THAT CATALYZE HYDROLYSIS OF
  PHOSPHATE ESTERS AT AN ALKALINE PH.
• BONE, PLACENTA, INTESTINE, KIDNEY AND LIVER.
• 80 (BONE/LIVER)

29
ALK PHOS

• CHOLESTASIS
• INTRAHEPATIC
• EXTRAHEPATIC (GALLSTONES/TUMOR)
• LOCALIZED (HEPATOMA)
• PATCHY (GRANULOMATOUS DZ)
• CHF, HYPERTHYROIDISM, LYMPHOMA, HYPERNEPHROMA

30
ALK PHOS

• GAMMA-GLUTAMYLTRANSFERASE (GGT)
• IF INC DISPROPORTIONATELY TO BILI INCREASE
  ---SARCOID, TB, FUNGAL, LYMPHOMA
• PBC/PSC

31
ALK PHOS

• PITFALLS DONE IN FASTING STATE
• PT WITH O/B BLOOD GROUP ARE SECRETORS AND CAN
  HAVE INC ALK-PHOS AFTER EATING A FATTY MEAL DUE
  TO THE RELEASE OF THE INTESTINAL ENZYME
• LOW IN HYPOTHYROIDISM, WILSONS DZ, HEMOLYSIS, AND
  CONG. HYPOPHOSPHTEMIA

32
ALK PHOS

• INTRAHEPATIC CHOLESTASIS
• PBC, DRUGS
• EXTRAHEPATIC CHOLESTASIS
• CBD STONES, STRICTURES, PANCREATIC CANCER

33
ALBUMEN

• SYTH. BY THE LIVER
• T1/2 3 WEEKS
• DEC USUALLY INDICATES LIVER DISEASE OF MORE THAN
  3 WEEKS
• SEPSIS

34
PROTHROMBIN TIME

• VIT K DEP CLOTTING FACTORS
• VIT K NOT ABSORBED (CHOLESTASIS), HEPATOCELLULAR
  DISEASE.
• MORE SENSITIVE THAN ALBUMEN
• PROLONGATION CORRELATES WITH DISEASE

35
OTHER TEST

• IMMUNOGLOBULINS
• IgM INCREASE WITH PBC
• ANA 1160 HOMGENEOUS W/ SMOOTH MUSCLE AB .
• AMA W/ PBC
• WILSONS LOW SERUM COPPER/CERULOPLASM

36
OTHER TESTS

• HEMOCHROMATOSIS TRANSFERRIN SAT 55, FERRITIN
  1000 UG/L
• A-1-AT DEF LUNG DZ, A-1-AT LEVELS ARE
• VIRAL SEROLOGIES

37
(No Transcript)
38
(No Transcript)