Transcript Evaluation of Abnormal Liver Function Tests

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
Negative serology,
asymptomatic
Negative serology
Serologies:
HAV IgM
HBsAg
HBcIgM
HCV Ab or
RNA
Positive serology
Negative Serology- Asymptomatic
Stop EtOH & meds; wt
loss; glucose control
6 months
Repeat LFTs
Abnormal
Ultrasound, ANA, smooth
muscle Ab, ceruloplasmin,
antitrypsin, gliadin &
endomysial Ab
Liver biopsy
Normal
Observation
☺
Negative Serology- Clinical
Signs/Symptoms of Liver Disease
Consider ultrasound,
ANA, smooth muscle
Ab, ceruloplasmin,
antitrypsin
Abnormal
Liver biopsy
☺
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 cause
Pregnancy, post pandrial
DETERMINE THE SOURCE
GGT
Normal
Increased
Bone origin
Hepatobiliary origin
ALP Hepatobiliary origin
Check AMA
USG
AMA Positive
USG abnormal parenchyma
Dilated bile ducts
LIVER BIOPSY
ERCP
MRCP
AMA negative
USG -Normal
Assess degree of ALP elevation
LIVER BIOPSY
MRCP
MIXED PICTURE
Hepatocellular pattern with Jaundice
• Alcoholic hepatitis
• Viral Hepatitis (A &E)
• Toxic hepatitis (Paracetamol, Wild
mushroom)
• Autoimmune
• Wilson’s
MIXED PICTURE
CHOLESTATIC PICTURE
• USG
Extrahepatic
• Choledocholithiasis
• Pancreatic cancer
• Cholangiocarcinoma
• PSC
Intrahepatic
(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, DyslipidemiaMetabolic 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