Elevated Liver Function Tests - Introduction to General Medicine - Lecture Slides, Slides of Medicine

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Senior talk 2009

MAISSAA JANBAIN, MD

 Abnormal LFTs are frequently detected in asymptomatic patients (1-4%).

 They do not always reflect liver diseases.

 They may be a marker of worse health outcomes.

 Medications (NSAIDs, Anitbiotics, statins,

antiepileptics and herbal preparations)

 Alcohol (AST/ALT >2:1, twofold elevation

of GGT)

 Hereditary hemochromatosis (Caucasian, iron,

TIBC, ferritin +/- liver biospy)

 Viral hepatitis: HBV ( HBsAg, anti HBsAg, anti HBc) and HCV ( ELISA, RIBA, PCR )

 Hepatic steatosis and NASH ( AST/ALT<1, ultrasound, CT or MRI)

 Wilson ‘s disease (age 5-25, serum ceruloplasmin, 24hr urine for copper, liver biopsy)

 Autoimmune hepatitis ( SPEP, ANA , SMA, LKMA, liver biopsy)

 Alpha 1 antitrypsin (associated emphysema, protein electrophoresis)

 If no cause was identified and ALT, AST elevation is less than tow fold, no more investigations.

 Biopsy is done otherwise eventhough it is less likely to provide diagnosis or lead to changes in management.

 Alk phos is derived from liver, bones, intestins and placenta.

 Levels vary with age, more elevated in children.

 To determine the source we check GGT or 5’ nucleotidase.

 Initial evaluation includes U/S and AMA followed by ERCP v/s liver biopsy.

 Very sensisitive for hepatobiliary disease but not specific.

 Can reflect pancreatic disease, MI, renal failure, diabetes, COPD, alcoholism.

 u/s shows biliary dilatation, and usually is followed by ERCP v/s CT scan.

 Choleodocholithiasis is the most common.

 Other causes include: malignancies, PSC, chronic pancreatitis and HIV cholangiopathy due to CMV or cryptosporidium (usually with no jaundice)

 Viral hepatitis (A, B, C, EBV, CMV)

 Alcoholic hepatitis

 PBC

 Drugs (anabolic and OCPs, usually reversible)

 Vanishing bile duct syndrome, adult bile ductopenia (chronic rejection, sarcoidosis)

 Benign recurrent cholestasis (AR)

 Pregnancy

 TPN, sepsis, post-op, Stauffer’s syndrome

 Usually acute self limited rarely fulminant especially if associated with chronic hep C.

 Manifestations vary with age, more silent in children.

 Incubation period of 30 days followed by abrupt prodromal symptoms then jaundice.

 Extrahepatic manifestations : vasculitis, optic neuritis, thrombocytopenia, aplastic anemia, transverse myelitis.

 IgM anti HAV is the gold standard for diagnosis.

 Start at the onset of symptoms and remain positive 4-6 months.

 Infected individuals are contagious during incubation and for a week after jaundice appears.

 Handwashing is very important !!! As HAV survives for up to 4 hrs on fingertips.

 Flaviviridae family; the prototype

Hepacivirus

 Rapid replication rate

 High mutation rate that allows him to

escape the immune recognition.

 Hep C infection can present as acute

hepatitis, chronic hepatitis, cirrhosis, HCC

or extrahepatic