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Evaluation of Abnormal Liver Function Tests

Evaluation of Abnormal Liver Function Tests. 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

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Evaluation of Abnormal Liver Function Tests

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  1. Evaluation of Abnormal Liver Function Tests

  2. Overview • Background • Elevated Transaminases • Isolated Hyperbilirubinaemia • Elevated Alkaline phosphatase • Mixed Picture • Case History

  3. 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

  4. HISTORY • Duration of abnormaL LFT • Symptoms- Jaundice, arthralgia, pain, pruritus, weight loss • Medication (Herbal) • Travel History • Transfusion • IV drug abuse • ALCOHOL

  5. EXAMINATION • Stigmata of chronic liver disease • Lympadenopathy • Periumbilical nodule • Palpable mass

  6. Transaminases • May not be elevated in chronic liver disease • HCV • Cirrhosis • Minimal ALT elevations (<1.5 X normal) • Race/Gender • Obesity • Muscle injury

  7. 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)

  8. Elevation in Serum Transaminases STEP 2 • Consider Autoimmune liver disease • Wilson’s Disease (<40) • Alpha 1 antitrypsin Deficiency (Emphysema)

  9. Elevation in Serum Transaminases STEP 3 • Exclude muscle disorder (CK) • Check TFT • ?Coeliac (Fe def) • Adrenal insufficiency STEP 4 • Liver Biopsy ? When

  10. Elevated AST & ALT, <4X normal Hx & physical; stop hepatotoxic meds Serologies: HAV IgM HBsAg HBcIgM HCV Ab or RNA LFTs, PT, albumin, CBC, Hep A/B/C, Fe, TIBC, Ferritin Negative serology, asymptomatic Negative serology Positive serology

  11. Negative Serology- Asymptomatic Stop EtOH & meds; wt loss; glucose control 6 months Repeat LFTs Abnormal Normal Ultrasound, ANA, smooth muscle Ab, ceruloplasmin, antitrypsin, gliadin & endomysial Ab Observation Liver biopsy ☺

  12. Negative Serology- Clinical Signs/Symptoms of Liver Disease Consider ultrasound, ANA, smooth muscle Ab, ceruloplasmin, antitrypsin Abnormal Liver biopsy ☺

  13. Isolated Hyperbilirubinemia • Product of hemoglobin breakdown Unconjugated (indirect)- insoluble • Haemolysis (Reticulocyte count) • Gilbert’s syndrome (3-7% population)

  14. 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

  15. Rule out physiological cause Pregnancy, post pandrial DETERMINE THE SOURCE GGT Normal Increased Bone origin Hepatobiliary origin Elevated Serum alkaline phoaphatase

  16. Check AMA USG AMA Positive USG abnormal parenchyma Dilated bile ducts AMA negative USG -Normal LIVER BIOPSY ERCP MRCP Assess degree of ALP elevation LIVER BIOPSY MRCP ALP Hepatobiliary origin

  17. MIXED PICTURE Hepatocellular pattern with Jaundice • Alcoholic hepatitis • Viral Hepatitis (A &E) • Toxic hepatitis (Paracetamol, Wild mushroom) • Autoimmune • Wilson’s

  18. MIXED PICTURE CHOLESTATIC PICTURE • USG Extrahepatic • Choledocholithiasis • Pancreatic cancer • Cholangiocarcinoma • PSC Intrahepatic (Drug induced,PBC,PSC,Pregnancy)

  19. 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

  20. 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

  21. 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

  22. 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)

  23. Treatment • Weight reduction- gradual • Diabetic and Lipid control • Vitamin E & Vitamin C • Metformin • Rosiglitazone • Pentoxifylline

  24. Mallory bodies

  25. NASH

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