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Gastro for finals

Learn to interpret liver function tests (LFTs) and hepatobiliary enzymes for diagnosis of liver disorders. Includes case studies and management.

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Gastro for finals

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  1. Gastro for finals OSCE edition

  2. Abdo exam • Intro

  3. Abdo exam • Intro • General inspection – patient & bedspace • Cachexia, icterus, pallor, discomfort, vomit bowels, catheter

  4. Abdo exam • Intro • General inspection – patient & bedspace • Hands • Clubbing, erythema, Dupuytren’s contracture, leukonychia, koilonychia, xanthomata, flap

  5. Abdo exam • Intro • General inspection – patient & bedspace • Hands • Head/neck • Conjunctival pallor, icteric sclera, xanthelasma, angular stomatitis, glossitis • Lymph nodes – Virchow’s

  6. Abdo exam • Intro • General inspection – patient & bedspace • Hands • Head/neck • Close inspection • Chest: spider naevi, gynaecomastia, lack of axillary hair, acanthosis nigricans • Abdomen: distension, scars, striae, hernias, caput medusae, Cullen’s sign, Grey-Turner’s sign, stomas

  7. Abdo exam • Intro • General inspection – patient & bedspace • Hands • Head/neck • Close inspection • Palpation • Superficial & deep in 9 regions • Liver & spleen with respiration • Ballot kidneys • AAA

  8. Abdo exam • Intro • General inspection – patient & bedspace • Hands • Head/neck • Close inspection • Palpation • Percussion • Liver & spleen • Shifting dullness • bladder

  9. Abdo exam • Intro • General inspection – patient & bedspace • Hands • Head/neck • Close inspection • Palpation • Percussion • Auscultation • Bowel sounds • Bruits

  10. Abdo exam • Intro • General inspection – patient & bedspace • Hands • Head/neck • Close inspection • Palpation • Percussion • Auscultation • Complete exam • Peripheral oedema • Hernial orifices, PR, ext genitalia

  11. Data interpretation: LFTs • Synthetic function • Albumin & total protein • INR/PT • bilirubin • Liver damage • ALT/AST • ALP • GGT

  12. Synthetic function • Albumin 35-52 g/l • Accounts for >50% plasma proteins • Manufactured in liver from amino-acids • Helps regulate osmotic pressure • Low in diarrhoea, liver disease, malnutrition, infection

  13. Synthetic function • Clotting factors • Prothrombin time specific to extrinsic pathway • If prolonged (in absence anticoagulants/vit k deficiency) can = liver damage • Bilirubin 0-21 umol/l • Conjugated in the liver • Might not cause jaundice if <60umol/l • Correlate with colour stools/urine

  14. Hepatobiliary enzymes • ALT 0-33 iu/l • Hepatocyte cytoplasm • AST • Hepatocyte cytoplasm, hepatocyte mitochondria, skeletal & cardiac muscle • ALT>AST : chronic liver disease • AST>ALT: cirrhosis & acute alcoholic hepatitis

  15. Hepatobiliary enzymes • ALP 35-104 iu/l • Canalicular surface of hepatocyte & bone, intestine, placenta • GGT 6-42 iu/l • Canalicular surface of hepatocyte • Alcohol • Both raised: highly suggestive of cholestasis • Isolated raised ALP: suspect bone/other • ALT or ALP raised more?? Hepatocellular vs cholestatic pattern

  16. Isolated jaundice • Haemolysis • Blood film, reticulocytes, LDH, haptoglobins • Gilbert’s syndrome • Inability to conjugate bilirubin • Intermittent jaundice precipitated by stress/illness/exercise

  17. Patterns • Cholestasis • Bilirubin high • ALP high • ALT normal • Hepatitic • ALT very high • Bilirubin higher if worse • ALP slightly up <2x • PT prolonged

  18. Case 1 • 85 year old lady presents with painless jaundice. • Bloods: bili111 ALT 32 ALP 1317 INR 1.0 • Other history? • On examination? • Further Ix? • Mx/prognosis?

  19. Case 2 • 40 year old female recently returned from holiday in Thailand, presents with malaise and abdominal pain • Bloods: bili150 ALT 5600 ALP 120 • Other history? • On examination? • Further Ix? • Mx/prognosis?

  20. Case 2 • Abroad for 2 months, no imms • Ate from roadside • Liver screen – Hep A • Platelets • Supportive mx • Infectious 2/52 or up to 6/12 in children/immunocompromised

  21. Case 3 • 21 year old man presents with icterus after having stayed up all night studying. One previous episode when had tonsillitis • Bloods: bili40 ALT 30 ALP 40 • Further ix?

  22. Case 3 • Bloods: FBC, reticulocytes, LDH, blood film all normal • Mx?

  23. Case 4 • 42 year old man with a background of obesity, hypertension and hypercholesterolaemia had LFTs checked at GP • Bloods: bili50 ALT 90 ALP 150 • Other history? • On examination? • Further Ix? • Mx/prognosis?

  24. Case 4 • Non-drinker, non-smoker • Examination: mild hepatomegaly • HbA1c: 6.4% • Liver USS • FIB4/NAFLD fibrosis score • Fibroscan, HCC screen etc

  25. Case 5 • 50 year old man presents to GP with 2/12 fatigue and 2/52 abdominal distension. Wife reports he is occasionally confused • Bloods: bili59 ALT 51 ALP 63 • Other history? • On examination? • Further Ix? • Mx/prognosis?

  26. Case 5 • Alcohol intake: >half a bottle of vodka/day for 20 years • Examination: scleral icterus, tremors, spider naevi, abdominal distension, splenomegaly • Bloods: low Hb, low platelets, high PT/INR, raised MCV, raised GGT • US liver • Alcohol cessation, nutrition

  27. CIWA score • Nausea/vomiting • Tremor • Sweats • Anxiety • Agitation • Tactile disturbances • Auditory disturbances • Visual disturbances • Headache • Orientation

  28. Case 6 • 42 year old man presents with pruritis. He has recently seen his GP for an episode of bloody diarrhoea • Bloods: bili35 ALT 47 ALP 317 • Other history? • On examination? • Further Ix? • Mx/prognosis?

  29. Case 6 • Bloody diarrhoea? • Bloods: FBC may be anaemia, plt can be low • AMA: negative • US abdomen • MRCP

  30. Case 7 • 46 year old woman visits GP with fatigue, anorexia, nausea, abdominal discomfort, mild pruritis & small joint arthralgia • Bloods: bili45 ALT 297 ALP 141 • Other history? • On examination? • Further Ix? • Mx/prognosis?

  31. Case 7 • May have icterus, pruritis. Genetic predisposition • May have spider naevi • Bloods: ANA, SMA • US abdomen • Liver biopsy • Corticosteroids & immunosuppressants

  32. Case 8 • 49 year old lady sees GP with fatigue. Occasional itch but no rash. Slightly overweight • Bloods: bili96 ALT 39 ALP 430 • Further ix? • Mx?

  33. Case 8 • Other autoimmune disease/fam hx • AMA, raised IgM • Screen to exclude HCC & varices • Ursodeoxycholic acid • Symptomatic mx: colestyramine • Fat soluble vits & osteoporosis

  34. Case 9 • 38 year old nurse has a routine occupational health blood test on joining NHS • Bloods: bili40 ALT 55 ALP 105 • Other history? • Further Ix?

  35. Case 9 • Trained abroad, ?immunised • Has had a needlestick injury 5 months ago

  36. Hepatitis serology!!! • HBsAg (surface antigen) first to appear, causes production of anti-HBs • HBsAg 1-6mo = acute, >6mo = chronic • Anti-HBs = immunity (exposure/immunisation) negative in chronic • Anti-HBc = previous or current infection • IgM anti-HBc = recent infection within 6mo • HBeAg – breakdown of core antigen from infected cells = marker of infectivity

  37. Case 9 • HBsAg: positive • Anti-HBs: negative • Anti-HBc: positive • Chronic infection

  38. Case 10 • HBsAg: negative • Anti-HBs: positive • Anti-HBc: negative • Immune due to vaccination

  39. Case 11 • HBsAg: negative • Anti-HBs: positive • Anti-HBc: positive • Immune due to infection, not a carrier

  40. Case 12 • HBsAg: positive • Anti-HBs: negative • Anti-HBc: positive • IgM anti-HBc: positive

  41. Case 13 • 63 year old man presents with abdominal distension worsening over several months & dark stools. PSHx abdominal surgery requiring blood transfusion in 80s • Bloods: bili 30 ALT 79 ALP 80

  42. Case 13 • Occasional alcohol use • Spider naevi, gynaecomastia, caput medsuae, ascites • Positive HCV antibodies • Antivirals • Assessment fibrosis & HCC screening

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