Abnormal Liver Tests - PowerPoint PPT Presentation

Loading...

PPT – Abnormal Liver Tests PowerPoint presentation | free to download - id: 433e55-OWM5M



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:

INR Prolonged by end stage liver disease, ... obesity and hyperlipidemia has a CMP which is normal except for AST194, ALT132. What do you want to know and/or do? – PowerPoint PPT presentation

Number of Views:199
Avg rating:3.0/5.0
Slides: 63
Provided by: maineG3
Learn more at: http://mdfpcases.org
Category:

less

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

Title: Abnormal Liver Tests


1
Abnormal Liver Tests
  • Harry Colt, MD
  • 04/5/10

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 cost effective 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 tests includes
  • history
  • physical
  • analysis of enzyme pattern
  • 1. hepatocellular or cholestatic
  • 2. magnitude of abnormality
  • 3. rate of change
  • further testing

7
History
  • HPI
  • most are asymptomatic
  • 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 travel history
  • raw oysters, clams, etc.
  • Family history (Gilberts, Wilsons,
    hemochromatosis, alpha one antitrypsin deficiency

9
Physical
  • most have no unusual findings
  • 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
(No Transcript)
14
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

15
Non-Liver Causes of Hepatocellular Pattern
  • inherited disorders of muscle metabolism
  • Acquired muscle disease
  • strenuous exercise

16
Case 1 62 yo man with hypertension, obesity
and hyperlipidemia has a CMP which is normal
except for AST194, ALT132. What else do you want
to know? What tests might you want to order?
17
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)

18
Additional Tests (Hepatocellular)
  • PCR for Hep C RNA
  • alpha one antitrypsin phenotyping
  • tissue transglutaminase Ab (TTG)
  • ultrasound
  • liver biopsy

19
Alcoholic Liver Disease
  • ASTgt ALT in vast majority
  • 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

20
(No Transcript)
21
(No Transcript)
22
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

23
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

24
(No Transcript)
25
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

26
Hepatic Steatosis and Nonalcoholic Steatohepatitis
  • most common cause of mild elevation of
    aminotransferases in Western world
  • ASTALT usually less than 11
  • ultrasound or CT can help 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

27
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

28
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

29
(No Transcript)
30
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

31
Non-Hepatic Causes
  • If other causes ruled out, consider celiac sprue
  • Test for tissue transglutaminasse Ab
  • 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

32
If ALT AST elevated, but all other blood tests
normal?
  • If AST, ALT lt2x normal, observe
  • If AST, ALT gt2x normal, biopsy

33
Case 62 yo man with hypertension, obesity,
hyperlipidemia has CMP notable for AST 194, ALT
132. What would you do?
34
Answer History (alcohol, meds, risk factors for
hepatitis, family history, etc.) Physical Analyz
e pattern Hepatocellular Stop alcohol and
non-essential meds Retest If remain elevated,
further workup
35
Further eval includes Hep C antibody Hep B
SAg Fe, TIBC SPEP
36
Further eval includes stop med(s) ultrasound e
tc.
37
CMAJ Feb. 1, 2005 172 (3)
38
Case 2 42 yo woman with hypertension has CMP
which is notable for alkaline phosphatase of
320. What do you do next?
39
  • 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

40
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. GGT
  • 2. Alk phos fractionation

41
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,
    estrogen), sarcoidosis, granulomatous disease,
    metastatic cancer

42
How to distinguish these entities?
  • Next step
  • ultrasound
  • antimitochondrial antibodies (R/O primary
    biliary cirrhosis)

43
  • 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

44
CMAJ Feb. 1, 2005 172(3)
45
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
  • Can R/O hemolysis with hgb, retic count,
    haptoglobin levels

46
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

47
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

48
Questions?
49
Cases
50
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?
51
History Pertinent history includes longstanding
alcohol abuse, consumption of raw oysters during
a recent vacation, and taking 2 g acetaminophen
for back pain daily
52
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?
53
Questions?
54
Case 4 A 40 yo woman has hypertension and
hyperlipidemia and is on HCTZ and simvastatin.
She is asymptomatic. A CMP reveals a total
bilirubin of 2.7 as the lone abnormality. What
would the most likely cause? What do you do?
55
Case 5 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?
56
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?
57
Case 6 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?
58
Case 7 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?
59
Case 8 A 27 yo man comes to the ER with right
sided abdominal pain, nausea, and vomiting for 2
days. He took 8 tylenol over a course of 6 hours
this morning. He was seen this past weekend in a
neighboring ER with a ETOH level of .30, but
denies any alcohol since. PE tender liver
edge, 2 cm below RCM
60
Case 8 (contd) Labs AIK Phos 161 AST
1401 ALT 604 INR 1.5 Tylenol level
15 Urine infected CT fatty liver What
is (are) the likely causes? What would you do?
61
Case 8 (contd) The following morning AIK
Phos 161?289 AST 1401?7,680 ALT 604?2,107 INR
1.5 ?2.4 What is (are) the likely
causes? What do you do now?
62
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