liver “ function ” test
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Liver “ Function ” Test. 2013 Mini-Lecture. Objectives. Understand the significance of Liver Function Tests Identify the patterns that indicate specific disease categories Identify the appropriate further work up of abnormalities. Case. - PowerPoint PPT PresentationTRANSCRIPT
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2013MINI-LECTURE
Liver “Function” Test
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Objectives
Understand the significance of Liver Function Tests
Identify the patterns that indicate specific disease categories
Identify the appropriate further work up of abnormalities
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Case
49 year old Female presents with chest pain and negative troponins admitted for monitoring, LFT in ED show AST: 57, ALT: 62, Alk Phos: wnl, T. Bili: wnl. What is the next step in management?
A: RUQ UltrasoundB: Hepatitis PanelC: Screen for Alcohol UseD: CT Scan Abdomen
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Etiology
Synthetic Function: Total protein, serum albumin, total bilirubin, prothrombin time
ALT: found primarily in HepatocytesAST: found in many sources- Liver, heart,
intestine, pancreaseAlkaline phosphatase: found in liver, bones,
intestines, and placentaBilirubin: Two sources- indirect (old red
cells), Direct (conjugated in liver)
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Patterns
Elevation in ALT & AST: primarily cellular injury Etiology: Acute Viral Hepatitis, Acetaminophen
toxicity, shock liver
Elevation in Alk Phos and Bilirubin: cholestasis or obstruction Etiology: choledocholithiasis, biliary stricture,
malignancy
Mixed: Serum Bilirubin can be elevated in both conditions
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Pearls for further evaluation
Albumin Low Albumin- suggests chronic process (cirrhosis/cancer) Normal- suggests acute process
Prothrombin Prolonged
suggests vitamin K deficiency 2/2 prolonged jaundice or malabsorption
Significant hepatocellular dysfunction (failure to correct w/ vit K administration indicates severe injury)
Bilirubin in Urine Indicates hepatobiliary disease (indirect not excreted by
kidney)
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Mild Aminotransferase Elevation Workup
Primary Causes Screen for alcohol abuse (AST/ALT > 2:1) Review medications
If Negative: then serology for hepatitis B/C, screen for hemochromatosis, then evaluate for fatty liver w/ RUQ US
Secondary Exclude muscle disorders Thyroid function tests Celiac disease Adrenal insufficiency
IF All negative: Autoimmune, Wilson’s dx, alpha 1 antitrypsin, consider biopsy or observe (pt w/ ALT/AST less that 2x ULN)
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Hyperbilirubinemia
Unconjugated Over production: hemolysis, extravasation of blood into
tissue, ineffective erythropoiesis Impaired Uptake: Heart failure, portosystemic shunts,
Gilberts, Drugs (Rifampicin and probenecid) Impaired conjugation: Gilberts, hyperthyroidism, Liver Dx,
Crigler-Najjar
Conjugated Extrahepatic: choledocholithiasis, tumors, PSC, AIDS,
pancreatitis, strictures, parasitic infxn Intrahepatic: hepatitis, PBC, Drugs, Sepsis/hypoperfusion,
infiltrative disease, TPN, Sickle cell, pregnancy, Dubin Johnson and Rotor Syndrome
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Alkaline Phosphatase
Source includes: bone, liver, placenta, varies w/ age Serum GGT: elevated in Liver Disease not Bone
disease Most common cause: chronic cholestasis or infiltrative
disease Primary biliary cirrhosis, primary sclerosis cholangitis Sarcoidosis, amyloidosis, liver metastasis
Initial Workup: RUQ Ultrasound Anti-mitochondrial Antibody Consider- MRCP or ERCP
Observe: if Alk phos <50% above normal
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Elevation of Several LFT’s
Hepatocellular pattern ALT/AST > 25 ULN only seen in hepatocullular dx With Jaundice
Alcholic AST:ALT.2 AST rarely > 300 units/L
Viral Aminotransferase> 500 u/L w/ ALT >AST
Toxic: i.e. Acetaminophen Shock liver Autoimmune and Wilson’s Dx
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Elevation of Several LFT’s
Predominantly Cholestatic Pattern Determine Intra vs Extra hepatic
RUQ U/S: assess for Biliary dilation
Extrahepatic: consider CT or MRCP or ERCP Common Causes: choledocholithiasis, malignancy,
PSC, PancreatitisIntrahepatic: broad differential
Work-up determined by clinic situation
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Summary
Described significance of each Liver function test
Identified common LFT abnormalities
Familiarized with basic initial work up of elevated Liver function Tests