serina farzin-nasab, md emory university family medicine residency program
TRANSCRIPT
![Page 1: Serina Farzin-Nasab, MD Emory University Family Medicine Residency Program](https://reader035.vdocument.in/reader035/viewer/2022062407/56649c765503460f9492b3c8/html5/thumbnails/1.jpg)
Serina Farzin-Nasab, MDEmory UniversityFamily Medicine Residency Program
![Page 2: Serina Farzin-Nasab, MD Emory University Family Medicine Residency Program](https://reader035.vdocument.in/reader035/viewer/2022062407/56649c765503460f9492b3c8/html5/thumbnails/2.jpg)
3 Categories:
1- Direct hepatocellular damage (transaminases)
2-Cholestasis ( bilirubin, alkaline phosphates)
3-Liver’s synthetic ability ( albumin, PT)
![Page 3: Serina Farzin-Nasab, MD Emory University Family Medicine Residency Program](https://reader035.vdocument.in/reader035/viewer/2022062407/56649c765503460f9492b3c8/html5/thumbnails/3.jpg)
Transaminitis
Hepatocyte necrosis leads to leakage of enzyme
Hepatitis Toxic injury Ischemic injury
![Page 4: Serina Farzin-Nasab, MD Emory University Family Medicine Residency Program](https://reader035.vdocument.in/reader035/viewer/2022062407/56649c765503460f9492b3c8/html5/thumbnails/4.jpg)
Hep C: liver cell death by apoptosis (programmed cell death) and by necrosis
1/3 pt’s with Hep C have persistently normal
serum transaminases
![Page 5: Serina Farzin-Nasab, MD Emory University Family Medicine Residency Program](https://reader035.vdocument.in/reader035/viewer/2022062407/56649c765503460f9492b3c8/html5/thumbnails/5.jpg)
Levels of aminotransferases can rise in Severe muscular exertion or other muscle injuries, polymyositis
Hypothyroidism
![Page 6: Serina Farzin-Nasab, MD Emory University Family Medicine Residency Program](https://reader035.vdocument.in/reader035/viewer/2022062407/56649c765503460f9492b3c8/html5/thumbnails/6.jpg)
AST and ALT levels do not follow a normal bell-shaped distribution
AST and ALT are higher in
obese pt’s, males and nonwhites ( blacks and Hispanics)
![Page 7: Serina Farzin-Nasab, MD Emory University Family Medicine Residency Program](https://reader035.vdocument.in/reader035/viewer/2022062407/56649c765503460f9492b3c8/html5/thumbnails/7.jpg)
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
![Page 8: Serina Farzin-Nasab, MD Emory University Family Medicine Residency Program](https://reader035.vdocument.in/reader035/viewer/2022062407/56649c765503460f9492b3c8/html5/thumbnails/8.jpg)
G) Growths (tumors)
H) Hemodynamic disorder (congestive heart failure)
I) Iron (hemochromatosis), copper (Wilson's disease) or alpha1-antitrypsin deficiency
M) Muscle injury
![Page 9: Serina Farzin-Nasab, MD Emory University Family Medicine Residency Program](https://reader035.vdocument.in/reader035/viewer/2022062407/56649c765503460f9492b3c8/html5/thumbnails/9.jpg)
Typical AST or ALT Values in Disease
![Page 10: Serina Farzin-Nasab, MD Emory University Family Medicine Residency Program](https://reader035.vdocument.in/reader035/viewer/2022062407/56649c765503460f9492b3c8/html5/thumbnails/10.jpg)
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.
MARKERS OF CHOLESTASIS
![Page 11: Serina Farzin-Nasab, MD Emory University Family Medicine Residency Program](https://reader035.vdocument.in/reader035/viewer/2022062407/56649c765503460f9492b3c8/html5/thumbnails/11.jpg)
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
![Page 12: Serina Farzin-Nasab, MD Emory University Family Medicine Residency Program](https://reader035.vdocument.in/reader035/viewer/2022062407/56649c765503460f9492b3c8/html5/thumbnails/12.jpg)
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 .
![Page 13: Serina Farzin-Nasab, MD Emory University Family Medicine Residency Program](https://reader035.vdocument.in/reader035/viewer/2022062407/56649c765503460f9492b3c8/html5/thumbnails/13.jpg)
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
![Page 14: Serina Farzin-Nasab, MD Emory University Family Medicine Residency Program](https://reader035.vdocument.in/reader035/viewer/2022062407/56649c765503460f9492b3c8/html5/thumbnails/14.jpg)
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.
![Page 15: Serina Farzin-Nasab, MD Emory University Family Medicine Residency Program](https://reader035.vdocument.in/reader035/viewer/2022062407/56649c765503460f9492b3c8/html5/thumbnails/15.jpg)
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
![Page 16: Serina Farzin-Nasab, MD Emory University Family Medicine Residency Program](https://reader035.vdocument.in/reader035/viewer/2022062407/56649c765503460f9492b3c8/html5/thumbnails/16.jpg)
Hepatic Cause of elevated AP
Hepatocellular disease (usually <3-fold increase)
• Alcoholic hepatitis• Viral hepatitis• Fatty infiltration of liver• Cirrhosis
![Page 17: Serina Farzin-Nasab, MD Emory University Family Medicine Residency Program](https://reader035.vdocument.in/reader035/viewer/2022062407/56649c765503460f9492b3c8/html5/thumbnails/17.jpg)
Hepatic Cause of elevated AP
Obstructive processes (usually >3-fold increase)
Choledocholithiasis Cancer of head of pancreas Cholangiocarcinoma Cholestatic hepatitis
![Page 18: Serina Farzin-Nasab, MD Emory University Family Medicine Residency Program](https://reader035.vdocument.in/reader035/viewer/2022062407/56649c765503460f9492b3c8/html5/thumbnails/18.jpg)
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
![Page 19: Serina Farzin-Nasab, MD Emory University Family Medicine Residency Program](https://reader035.vdocument.in/reader035/viewer/2022062407/56649c765503460f9492b3c8/html5/thumbnails/19.jpg)
Hepatic Cause of elevated AP
Medications:CaptoprilErythromycinGold salts PhenothiazinesTrimethoprimand-sulfamethoxazoleAnticonvulsants
![Page 20: Serina Farzin-Nasab, MD Emory University Family Medicine Residency Program](https://reader035.vdocument.in/reader035/viewer/2022062407/56649c765503460f9492b3c8/html5/thumbnails/20.jpg)
Increased synthesis of AP in Diabetes mellitus 44% of patients with DM have increased AP
![Page 21: Serina Farzin-Nasab, MD Emory University Family Medicine Residency Program](https://reader035.vdocument.in/reader035/viewer/2022062407/56649c765503460f9492b3c8/html5/thumbnails/21.jpg)
Common Non hepatic Causes of Elevated GGT
Acetaminophen overdose Acute myocardial infarction Acute pancreatitis Anticonvulsants (phenytoin, phenobarbital, carbamazepine)
![Page 22: Serina Farzin-Nasab, MD Emory University Family Medicine Residency Program](https://reader035.vdocument.in/reader035/viewer/2022062407/56649c765503460f9492b3c8/html5/thumbnails/22.jpg)
Brain tumor Diabetes mellitus Hyperthyroidism Infectious mononucleosis Epilepsy
![Page 23: Serina Farzin-Nasab, MD Emory University Family Medicine Residency Program](https://reader035.vdocument.in/reader035/viewer/2022062407/56649c765503460f9492b3c8/html5/thumbnails/23.jpg)
Albumin
An Index of liver synthetic capacity Low albumin level and no other LFT abnormalities are likely to have a non hepatic
cause
![Page 24: Serina Farzin-Nasab, MD Emory University Family Medicine Residency Program](https://reader035.vdocument.in/reader035/viewer/2022062407/56649c765503460f9492b3c8/html5/thumbnails/24.jpg)
Albumin
Non hepatic causes of low Albumin: Inflammatory states such as burns,
trauma,& sepsis Active rheumatic disorders Severe end-stage malnutrition Pregnancy Proteinuria
![Page 25: Serina Farzin-Nasab, MD Emory University Family Medicine Residency Program](https://reader035.vdocument.in/reader035/viewer/2022062407/56649c765503460f9492b3c8/html5/thumbnails/25.jpg)
PT Does not become abnormal until more
than 80%of liver synthetic capacity is lost
Useful to be followed in acute hepatic failure
(Factor 7 has very short half life)
![Page 26: Serina Farzin-Nasab, MD Emory University Family Medicine Residency Program](https://reader035.vdocument.in/reader035/viewer/2022062407/56649c765503460f9492b3c8/html5/thumbnails/26.jpg)
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
![Page 27: Serina Farzin-Nasab, MD Emory University Family Medicine Residency Program](https://reader035.vdocument.in/reader035/viewer/2022062407/56649c765503460f9492b3c8/html5/thumbnails/27.jpg)
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.
![Page 28: Serina Farzin-Nasab, MD Emory University Family Medicine Residency Program](https://reader035.vdocument.in/reader035/viewer/2022062407/56649c765503460f9492b3c8/html5/thumbnails/28.jpg)
QUIZ
Other than hepatitis, causes of elevatedserum GGT include all of the following
except:
A. Diabetes mellitus.B. Hypothyroidism.C. Brain tumor.D. Infectious mononucleosis.E. Acute myocardial infarction
![Page 29: Serina Farzin-Nasab, MD Emory University Family Medicine Residency Program](https://reader035.vdocument.in/reader035/viewer/2022062407/56649c765503460f9492b3c8/html5/thumbnails/29.jpg)
Answer : B
Hyperthyroidism is associated with
elevated GTT
![Page 30: Serina Farzin-Nasab, MD Emory University Family Medicine Residency Program](https://reader035.vdocument.in/reader035/viewer/2022062407/56649c765503460f9492b3c8/html5/thumbnails/30.jpg)
QUIZ
The greatest increase in serum alkalinephosphatase is generally seen in a
patientwith 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
![Page 31: Serina Farzin-Nasab, MD Emory University Family Medicine Residency Program](https://reader035.vdocument.in/reader035/viewer/2022062407/56649c765503460f9492b3c8/html5/thumbnails/31.jpg)
Answer: A
Primary billiary cirrhosis
![Page 32: Serina Farzin-Nasab, MD Emory University Family Medicine Residency Program](https://reader035.vdocument.in/reader035/viewer/2022062407/56649c765503460f9492b3c8/html5/thumbnails/32.jpg)
QUIZ
In patients with viral hepatitis, the serum AST level is usually higher than the serum ALT level
A. True.
B. False
![Page 33: Serina Farzin-Nasab, MD Emory University Family Medicine Residency Program](https://reader035.vdocument.in/reader035/viewer/2022062407/56649c765503460f9492b3c8/html5/thumbnails/33.jpg)
False
![Page 34: Serina Farzin-Nasab, MD Emory University Family Medicine Residency Program](https://reader035.vdocument.in/reader035/viewer/2022062407/56649c765503460f9492b3c8/html5/thumbnails/34.jpg)
QUIZ
Normally, most of the total bilirubin is conjugated.
A. True
B. False
![Page 35: Serina Farzin-Nasab, MD Emory University Family Medicine Residency Program](https://reader035.vdocument.in/reader035/viewer/2022062407/56649c765503460f9492b3c8/html5/thumbnails/35.jpg)
False
70% of total Billi is non conjugated