evaluation of abnormal liver function tests dr deb datta consultant gastroenterolgist
TRANSCRIPT
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Evaluation of Abnormal Liver Function Tests
Dr Deb Datta
Consultant Gastroenterolgist
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Overview
• Background
• Elevated Transaminases
• Isolated Hyperbilirubinaemia
• Elevated Alkaline phosphatase
• Mixed Picture
• Case History
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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
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HISTORY
• Duration of abnormaL LFT• Symptoms- Jaundice, arthralgia, pain,
pruritus, weight loss• Medication (Herbal)• Travel History• Transfusion• IV drug abuse• ALCOHOL
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EXAMINATION
• Stigmata of chronic liver disease
• Lympadenopathy
• Periumbilical nodule
• Palpable mass
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Transaminases
• May not be elevated in chronic liver disease– HCV– Cirrhosis
• Minimal ALT elevations (<1.5 X normal)– Race/Gender– Obesity – Muscle injury
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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)
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Elevation in Serum Transaminases
STEP 2
• Consider Autoimmune liver disease
• Wilson’s Disease (<40)
• Alpha 1 antitrypsin Deficiency (Emphysema)
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Elevation in Serum Transaminases
STEP 3
• Exclude muscle disorder (CK)
• Check TFT
• ?Coeliac (Fe def)
• Adrenal insufficiency
STEP 4
• Liver Biopsy ? When
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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
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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
☺
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Consider ultrasound, ANA, smooth muscle Ab, ceruloplasmin,
antitrypsin
Liver biopsy
Negative Serology- Clinical Signs/Symptoms of Liver Disease
Abnormal
☺
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Isolated Hyperbilirubinemia
• Product of hemoglobin breakdown
Unconjugated (indirect)- insoluble• Haemolysis (Reticulocyte count)• Gilbert’s syndrome (3-7% population)
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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
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Elevated Serum alkaline phoaphatase
Rule out physiological causePregnancy, post pandrial
DETERMINE THE SOURCEGGT
Normal Increased
Bone origin Hepatobiliary origin
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ALP Hepatobiliary origin
Check AMAUSG
AMA PositiveUSG abnormal parenchyma
Dilated bile ductsAMA negativeUSG -Normal
LIVER BIOPSYERCPMRCP
Assess degree of ALP elevation
LIVER BIOPSYMRCP
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MIXED PICTURE
Hepatocellular pattern with Jaundice
• Alcoholic hepatitis
• Viral Hepatitis (A &E)
• Toxic hepatitis (Paracetamol, Wild mushroom)
• Autoimmune
• Wilson’s
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MIXED PICTURE
CHOLESTATIC PICTURE• USGExtrahepatic• Choledocholithiasis• Pancreatic cancer• Cholangiocarcinoma• PSCIntrahepatic(Drug induced,PBC,PSC,Pregnancy)
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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
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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
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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
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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?
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• 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 !!!’
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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
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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)
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Treatment
• Weight reduction- gradual
• Diabetic and Lipid control
• Vitamin E & Vitamin C
• Metformin
• Rosiglitazone
• Pentoxifylline
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Mallory bodies
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NASH
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THANK YOU