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Making Sense of LFTs

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malignant liver disease. Lesser increase: viral hepatitis, cirrhosis, congestive hepatopathy ... do Patients with Liver Disease Present? Asymptomatic ... – PowerPoint PPT presentation

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Title: Making Sense of LFTs


1
Making Sense of LFTs
  • Alliance of Internal Medicine
  • October 2004

2
acknowledgments
  • Images used in this presentation were downloaded
    from Google Images and are being used for the
    express purpose of education

3
Markers for the Liver
  • Detect the presence of liver disease
  • Distinguish among different types of liver
    disorders
  • Gauge the extent of known liver damage
  • Follow the response to treatment

4
LFTs is Not the Correct Term
  • Liver Function Tests suggests that what we are
    measuring is the function of the liver
  • Standard lab tests actually measure injury to
    hepatocytes, or altered bile flow
  • Also be careful about speaking about a liver
    panel

5
Risk Factors for Liver Disease
  • Age and gender lifestyle / genetic
    predisposition
  • Hemochroamtosis , alpha1- antitrypsin deficiency,
    Wilsons disease (generally rare)
  • Exposure risk family with hepatitis
  • Alcoholism, diabetes, hyperlipidemia

6
Personal Habits and Exposures
  • Alcohol use
  • Exposure to blood/ blood products
  • Sexual history
  • Prior biliary surgery

7
Physical Examination Jaundice
8
Spider Angioma
9
Asterixis
10
Caput medusa
11
Nodular Liver
12
Ascites
13
Gynecomastia
14
Muscle Wasting
15
Laboratory Findings
16
Hepatocellular Injury
  • Aspartate aminotransferase (AST)
  • Alanine aminotransferase (ALT)

17
Aminotransferases
  • Aspartate Aminotransferase (AST)
  • In the mitochondria and cytosol
  • Cardiac, kidney, skeletal muscle, brain
  • Alanine aminotransferase (ALT)
  • In the cytosol
  • Primarily in the liver

18
  • High concentration in the hepatocytes
  • Liver cell injury releases
  • Elevation guides you to the liver but not to
    the cause

19
Generalizations
  • AST ALT
  • Equal elevation viral / toxic injury
  • Extremely high ischemia
  • AST ALT 21 or greater alcohol
  • REMEMBER THAT AST is not only from liver

20
Ductular Injury and Cholestasis
  • Alkaline phosphatase
  • Bilirubin

21
Alkaline Phosphatase
  • Canalicular region of the hepatocytes
  • Bile duct cells
  • Ductular obstruction and cholestatsis leads to
    increased production of Alk phos and the release
    of alk phos from damaged cells

22
Alkaline Phosphatase
  • Elevations
  • 4x normal highly suggestive of ductular injury
  • Intrahepatic cholestasis
  • infiltrative processes
  • extrahepatic biliary obstruction
  • primary sclerosing cholangitis
  • malignant liver disease
  • Lesser increase viral hepatitis, cirrhosis,
    congestive hepatopathy

23
Alkaline Phosphatase
  • Where else does it come from
  • bone, adrenal cortex, placenta, intestine,
    kidney, lungs, leukocytes
  • (bone and liver are primary source)
  • Differentiation
  • Fractionation
  • 5-nucleotidase measure
  • gamma-glutamyl transpeptidase (GGT)

24
Bilirubin
  • Breakdown of red blood cells
  • Bilirubin cycle
  • Hepatic uptake from the circulation
  • Intracellular conjugation of bilirubin
  • Canalicular secretion of bilirubin
  • Conjugated bilirubin direct
  • Unconjugated indirect

25
Bilirubin
  • Why increased?
  • liver / ductal disease
  • Red cell breakdown
  • Is the urine dark?
  • Conjugated bilirubin

26
Liver Synthetic Function
  • Albumin
  • Clotting cascade

27
Albumin
  • Useful test of hepatic synthetic function
  • Better for chronic than acute because of long
    half life (28 days)
  • Many other things effect albumin level
  • Nutritional status
  • Catabolism
  • Dilution
  • Enhanced GI or renal loss

28
Clotting Factors
  • Prothrombin time
  • Factors II, IV, IX and X vitamin K dependent
    coagulation factor proenzymes
  • Need intact hepatic synthesis
  • Adequate intestinal absorption of lipid soluble
    vitamin K
  • Other things influence vit K
  • Cholestatsis , nutritional deprivation
  • To test for intact hepatic function give vit K

29
The ABCs of Hepatitis
30
Hepatitis A
  • Anti-HAV IgM antibody (acute infection)
  • Anti-HAV IgG antibody (immunity)

31
Hepatitis B markers
  • HBsAg- protein on outer envelop of virus
  • HBcAb-antibody formed against the core protein
    surrounding the viral DNA
  • HBeAg- structural portion of core protein
    indicative of active replication of HBV
  • HBsAb-antibody directed at the surface antigen

32
Hepatitis C
  • Anti-HCV antibodies
  • Enzyme immunoassay
  • Recombinant immunoblot assay (RIBA-2)
  • Detection / characterization of HCV RNA
  • Qualitative reverse transcription polymerase
    chain reaction (RT-PCR)
  • Quantitative test for HCV RNA level
  • Genotype determination

33
Viral hepatitis
34
How do Patients with Liver Disease Present?
  • Asymptomatic (increased transaminases)
  • History and Physical examination
  • Identify risk factors
  • Viral markers
  • Drug removal
  • Imaging
  • Liver biopsy

35
How do Patients with Liver Disease Present?
  • Jaundice
  • Rapid designation of cause important
  • Function problem
  • Flow problem
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