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Abnormal Liver Function Tests

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Title: M&M Author: Martin Khabbaz Last modified by: Family & Preventive Medicine Created Date: 12/14/2005 2:38:12 AM Document presentation format – PowerPoint PPT presentation

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Title: Abnormal Liver Function Tests


1
Abnormal Liver Function Tests
  • Serina Farzin-Nasab, MD
  • Emory University
  • Family Medicine Residency Program

2
  • 3 Categories
  • 1- Direct hepatocellular damage (transaminases)
  •  
  • 2-Cholestasis ( bilirubin, alkaline phosphates)
  •  
  • 3-Livers synthetic ability ( albumin, PT)

3
  • Transaminitis
  • Hepatocyte necrosis leads to leakage of enzyme
  •  
  • Hepatitis
  • Toxic injury
  • Ischemic injury

4
  • Hep C liver cell death by apoptosis (programmed
    cell death) and by necrosis
  • 1/3 pts with Hep C have persistently normal
    serum transaminases

5
  • Levels of aminotransferases can rise in Severe
    muscular exertion or other muscle injuries,
    polymyositis
  • Hypothyroidism

6
  •  AST and ALT levels do not follow a normal
    bell-shaped distribution  
  •  
  •  
  • AST and ALT are higher in obese pts, males
    and nonwhites ( blacks and Hispanics)

7
  • Causes of Elevated ALT or AST Values in
    Asymptomatic Patients
  • A) Autoimmune hepatitis
  • B) Hepatitis B
  • C) Hepatitis C
  • D) Drugs or toxins
  • E) Ethanol
  • F) Fatty liver

8
  • G) Growths (tumors)
  • H) Hemodynamic disorder (congestive heart
    failure)
  • I) Iron (hemochromatosis), copper (Wilson's
    disease) or alpha1-antitrypsin deficiency
  • M) Muscle injury

9
  •    Typical AST or ALT Values in Disease
  •  

10
MARKERS OF CHOLESTASIS
  • Cholestasis reflected in abnormal bilirubin and
    AP levels
  • In acute bile duct obstruction from a gallstone,
    AST and ALT levels often reach 500 U per L or
    more in the first hours , whereas AP and GGT
    levels can take several days to rise.

11
  • Elevation of GGT alone results from enzyme
    induction by alcohol or aromatic medicatios
  • GGT is elevated in persons who drink 3 or more
    per day

12
Direct/conjugated hyperbilirubinemia
  • Conjugated bilirubin levels do not rise until the
    liver has lost approximately half of its
    excretory ability.
  • The presence of conjugated bilirubin in the urine
    ( urine dipstick), is always indicative of
    hepatobiliary disease .

13
Indirect/uncongealed Hyperbilirubinemia
  • Gilbert syndrome
  • Common benign inherited disorder
  • Levels between 2 and 3 mg/d
  • Patients develop detectable jaundice during
    acute illness or starvation

14
  • Hemolysis
  • Confirmed by an elevated retic count increased
    haptoglobin levels.
  • In adults, no serious liver disease will
  • cause elevation of indirect bili alone
    without a concurrent rise in direct bili levels.

15
AP
  • Elevated levels are found in adolescents,
    children (secondary to bone growth), and pregnant
    women
  • Women with persistently elevated AP levels
  • primary biliary cirrhosis
  • Confirmed by a serum antimitochondrial antibody
    test

16
Hepatic Cause of elevated AP
  • Hepatocellular disease (usually lt3-fold increase)
  • Alcoholic hepatitis
  • Viral hepatitis
  • Fatty infiltration of liver
  • Cirrhosis

17
Hepatic Cause of elevated AP
  • Obstructive processes (usually gt3-fold increase)
  • Choledocholithiasis
  • Cancer of head of pancreas
  • Cholangiocarcinoma
  • Cholestatic hepatitis

18
Hepatic Cause of elevated AP
  • Infiltrative, neoplastic, Primary or metastatic
    carcinomas (15- to 20-fold increase)
  • Primary biliary cirrhosis
  • Amyloidosis
  • Hepatic congestion caused by heart disease
  • Infectious mononucleosis

19
Hepatic Cause of elevated AP
  • Medications
  • Captopril
  • Erythromycin
  • Gold salts
  • Phenothiazines
  • Trimethoprimand-sulfamethoxazole
  • Anticonvulsants

20
  • Increased synthesis of AP in Diabetes mellitus
  • 44 of patients with DM have increased AP

21
Common Non hepatic Causes of Elevated GGT
  • Acetaminophen overdose
  • Acute myocardial infarction
  • Acute pancreatitis
  • Anticonvulsants (phenytoin, phenobarbital,
  • carbamazepine)

22
  • Brain tumor
  • Diabetes mellitus
  • Hyperthyroidism
  • Infectious mononucleosis
  • Epilepsy

23
Albumin
  • An Index of liver synthetic capacity
  • Low albumin level and no other LFT
  • abnormalities are likely to have a non hepatic
    cause

24
Albumin
  • Non hepatic causes of low Albumin
  • Inflammatory states such as burns, trauma,
  • sepsis
  • Active rheumatic disorders
  • Severe end-stage malnutrition
  • Pregnancy
  • Proteinuria

25
PT
  • Does not become abnormal until more than 80of
    liver synthetic capacity is lost
  • Useful to be followed in acute hepatic failure
  • (Factor 7 has very short half life)

26
PT
  • Vitamin K deficiency
  • Chronic cholestasis or fat malabsorption
  • A trial of vitamin K injections ( 5 mg /day SQ x
    3 days) practical way to exclude vitamin K
    deficiency
  • PT should improve within a few days

27
Ammonia
  • Concentrations are much higher in the brain than
    in the blood and therefore do not correlate well
  • It is not unusual for the blood ammonia to be
    normal in a patient who is in a coma from hepatic
    encephalopathy.

28
QUIZ
  • Other than hepatitis, causes of elevated
  • serum GGT include all of the following except
  • A. Diabetes mellitus.
  • B. Hypothyroidism.
  • C. Brain tumor.
  • D. Infectious mononucleosis.
  • E. Acute myocardial infarction

29
  • Answer B
  • Hyperthyroidism is associated with
  • elevated GTT

30
QUIZ
  • The greatest increase in serum alkaline
  • phosphatase is generally seen in a patient
  • with which of the following conditions?
  • A. Primary biliary cirrhosis.
  • B. Alcoholic hepatitis.
  • C. Viral hepatitis.
  • D. Fatty infiltration of the liver.
  • E. Cancer of the head of the pancreas

31
  • Answer A
  • Primary billiary cirrhosis

32
QUIZ
  • In patients with viral hepatitis, the serum
    AST level is usually higher than the serum ALT
    level
  • A. True.
  • B. False

33
  • False

34
QUIZ
  • Normally, most of the total bilirubin is
    conjugated.
  • A. True
  • B. False

35
  • False
  • 70 of total Billi is non conjugated
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