evaluation of abnormal liver function tests dr deb datta consultant gastroenterolgist
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Evaluation of Abnormal Liver Function Tests
Dr Deb Datta
Consultant Gastroenterolgist
Overview
• Background
• Elevated Transaminases
• Isolated Hyperbilirubinaemia
• Elevated Alkaline phosphatase
• Mixed Picture
• Case History
Background
• Liver function tests ordered routinely• 1-4% of asymptomatic patients have
abnormal values• Population based survey-8.9% raised ALT• OBESITY• Serious underlying disease uncommon• Diagnosis often reached non invasively• No consensus on cost effective approach
HISTORY
• Duration of abnormaL LFT• Symptoms- Jaundice, arthralgia, pain,
pruritus, weight loss• Medication (Herbal)• Travel History• Transfusion• IV drug abuse• ALCOHOL
EXAMINATION
• Stigmata of chronic liver disease
• Lympadenopathy
• Periumbilical nodule
• Palpable mass
Transaminases
• May not be elevated in chronic liver disease– HCV– Cirrhosis
• Minimal ALT elevations (<1.5 X normal)– Race/Gender– Obesity – Muscle injury
Elevation in Serum Transaminases
STEP 1
• Medications, herbal treatment, drugs
• Screen for alcohol abuse (AST/ALT>2:1)
• Obtain serology for Hepatitis B & C
• Screen for Haemochromatosis (TIBC>45%)
• USG (?Fatty Liver)
Elevation in Serum Transaminases
STEP 2
• Consider Autoimmune liver disease
• Wilson’s Disease (<40)
• Alpha 1 antitrypsin Deficiency (Emphysema)
Elevation in Serum Transaminases
STEP 3
• Exclude muscle disorder (CK)
• Check TFT
• ?Coeliac (Fe def)
• Adrenal insufficiency
STEP 4
• Liver Biopsy ? When
Elevated AST & ALT, <4X normal
Hx & physical; stop hepatotoxic meds
LFTs, PT, albumin, CBC, Hep A/B/C, Fe,
TIBC, Ferritin
Positive serologyNegative serologyNegative serology,
asymptomatic
Serologies:HAV IgMHBsAgHBcIgMHCV Ab or RNA
Stop EtOH & meds; wt loss; glucose control
Repeat LFTs
ObservationUltrasound, ANA, smooth muscle Ab, ceruloplasmin,
antitrypsin, gliadin & endomysial Ab
Negative Serology- Asymptomatic
Liver biopsy
Abnormal Normal
6 months
☺
Consider ultrasound, ANA, smooth muscle Ab, ceruloplasmin,
antitrypsin
Liver biopsy
Negative Serology- Clinical Signs/Symptoms of Liver Disease
Abnormal
☺
Isolated Hyperbilirubinemia
• Product of hemoglobin breakdown
Unconjugated (indirect)- insoluble• Haemolysis (Reticulocyte count)• Gilbert’s syndrome (3-7% population)
Alkaline Phosphatase
• Produced by biliary epithelial cells– Non-specific to liver: bone, intestine, placenta
• Elevations– Biliary duct obstruction– Primary biliary cirrhosis– Primary sclerosing cholangitis– Infiltrative liver disease- ie sarcoid, lymphoma– Hepatitis/cirrhosis– Medications
Elevated Serum alkaline phoaphatase
Rule out physiological causePregnancy, post pandrial
DETERMINE THE SOURCEGGT
Normal Increased
Bone origin Hepatobiliary origin
ALP Hepatobiliary origin
Check AMAUSG
AMA PositiveUSG abnormal parenchyma
Dilated bile ductsAMA negativeUSG -Normal
LIVER BIOPSYERCPMRCP
Assess degree of ALP elevation
LIVER BIOPSYMRCP
MIXED PICTURE
Hepatocellular pattern with Jaundice
• Alcoholic hepatitis
• Viral Hepatitis (A &E)
• Toxic hepatitis (Paracetamol, Wild mushroom)
• Autoimmune
• Wilson’s
MIXED PICTURE
CHOLESTATIC PICTURE• USGExtrahepatic• Choledocholithiasis• Pancreatic cancer• Cholangiocarcinoma• PSCIntrahepatic(Drug induced,PBC,PSC,Pregnancy)
Other Liver Labs
• Albumin– decreased by trauma, inflammatory
conditions, malnutrition• Prothrombin time (PT)
-no change until liver loses 80% capacity• Ammonia
– No correlation between brain & serum values– Related to encephalopathy
Summary
• Algorithms based on poor quality or absence of evidence
• Most asymptomatic patients can safely be followed for a period of time to see if abnormalities resolve
• If lab abnormalities persist be thoughtful with ordering
48 yr male lawyer
• Dyspepsia• HP – negative• PPI -4 weeks• No better – Right hypochondrial
‘discomfort’• DM Type 2 (Diet), Simvastatin (CH -5.8)• Weight – 93.5 Kg• Alcohol - rare
48 yr male lawyer
• USG and new PPI• ‘Increased echogenicity- fatty liver’• ALT-78• Asymptomatic but very anxious• Hepatitis serology – negative – f/up 3
months• ALT-92 Cholesterol -6.4 Glucose-8• WHAT NOW?
• Stop statin and repeat blood in 3 months
• Continue statin and repeat blood in 3 months
• Strict diet, exercise programme and monitor
• Liver biopsy
• Do nothing – ‘go away !!!’
Nonalcoholic steatohepatitis
• No significant alcohol but liver biopsy similar to alcoholic steatohepatitis
• No hepatitis B or C
• Central obesity, type 2 DM, Dyslipidemia- Metabolic syndrome
• Men – 20-40% of population
• ?Insulin resistance /?oxidative injury
Nonalcoholic steatohepatitis
• Stable condition- compared to ALD
• Asymptomatic- ?fatigue
• Role of liver biopsy - prognosis
• 8-26% – histological progression- linked with obesity, liver biopsy –balloon degeneration, Mallory hyaline
• Cirrhosis – 3-15%( >45,0besity,DM)
Treatment
• Weight reduction- gradual
• Diabetic and Lipid control
• Vitamin E & Vitamin C
• Metformin
• Rosiglitazone
• Pentoxifylline
Mallory bodies
NASH
THANK YOU
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