Abnormal liver function tests R

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Abnormal liver function testsR ???

• UpToDate
• Last literature review version 16.1 ?? 2008   
• This topic last updated ??? 13, 2007

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EPIDEMIOLOGY

• The sensitivity and specificity of the serum
  aminotransferases (particularly serum ALT) for
  discriminating those with and without liver
  disease depends upon the cutoff values chosen to
  define an abnormal test.
• At lease two large studies suggested that the
  cutoff values should be adjusted for gender and
  body mass index.

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How to approach

• History (Hx)
• Physical examination (PE)
• Laboratory testing (Lab) 

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Hx

• The use of or exposure to any chemical or
  medication (including herbal therapies)
• The duration of LFT abnormalities

• The presence of any accompanying symptoms
• Jaundice
• Arthralgias, myalgias
• Rash
• Anorexia, weight loss
• Abdominal pain
• Fever
• Pruritus
• Changes in the urine and stool

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Hx

• Possible parenteral exposures
• Transfusions
• Intravenous and intranasal drug use
• Tattoos
• Sexual activity

• Recent travel history
• Exposure to people with jaundice
• Exposure to possibly contaminated foods
• Occupational exposure to hepatotoxins
• Alcohol consumption

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Hx (for example)

• Arthralgias and myalgias predating jaundice
• Favor viral or drug-related hepatitis
• Jaundice associated with the sudden onset of
  severe right upper quadrant pain and shaking
  chills
• Favor choledocholithiasis and ascending
  cholangitis
• Brabra

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PE

• Longstanding diseases
• temporal and proximal muscle wasting
• Stigmata of chronic liver disease
• spider nevi
• palmar erythema
• gynecomastia
• caput medusae

• Laennec's cirrhosis and occasionally in other
  types of cirrhosis
• Dupuytren's contractures
• parotid gland enlargement
• testicular atrophy

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PE

• Abdominal malignancy
• An enlarged left supraclavicular node (Virchow's
  node)
• Periumbilical nodule (Sister Mary Joseph's
  nodule)

• Hepatic congestion
• Jugular venous distension, a sign of right sided
  heart failure
• Advanced cirrhosis
• A right pleural effusion, in the absence of
  clinically apparent ascites

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PE

• Size and consistency of the liver
• Size of the spleen
• Ascites (fluid wave or shifting dullness)
• An enlarged tender liver
• viral or alcoholic hepatitis
• acutely congested liver secondary to right-sided
  heart failure (less)

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Lab

• Alk-P
• disproportionate elevation in cholestatic process
  than serum aminotransferases (opposed for
  hepatocellular injury)
• Albumin
• Low cirrhosis or cancer
• Normal viral hepatitis or choledocholithiasis

• PT
• vitamin K deficiency
• significant hepatocellular dysfunction
• Bilirubin in the urine
• Hyperbilirubinemia
• conjugated bilirubin
• unconjugated bilirubin
• Early sign of liver disease

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Mild Chronic Elevation in Serum Aminotransferases

• Step one 
• Medications and supplements
• Alcohol use
• Viral hepatitis B and C
• Hemochromatosis
• Fatty liver (hepatic steatosis and
  steatohepatitis  )

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Mild Chronic Elevation in Serum Aminotransferases

• Step two
• Muscle disorders
• Thyroid disease
• Celiac disease (less)
• Adrenal insufficiency (less)
• Anorexia nervosa (less)

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Mild Chronic Elevation in Serum Aminotransferases

• Step three 
• Autoimmune hepatitis
• Wilson's disease 
• Alpha-1-antitrypsin deficiency 

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Mild Chronic Elevation in Serum Aminotransferases

• Step four 
• A liver biopsy is often considered in patients in
  whom all of the above testing has been
  unyielding.
• However, in some settings, the best course may be
  observation.

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Predominantly hepatocellular pattern with
jaundice 
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Alcoholic hepatitis 

• ASTALT ratio of at least 21
• AST rarely exceeds 300 U/L

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Viral hepatitis 

• Hepatitis A IgM antibody
• Hepatitis B surface antigen
• Hepatitis B core IgM antibody
• Hepatitis C viral RNA
• acute (aminotransferases greater than 500 U/L
  with the ALT greater than or equal to the AST )
• hepatitis C is an uncommon cause of acute viral
  hepatitis

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Toxic hepatitis 

• Predictable drug reactions
• dose-dependent
• affect all patients
• Ex acetaminophen
• UnPredictable drug reactions
• any drug can cause an idiosyncratic reaction
• Environmental toxins
• vinyl chloride, herbal preparations
• mushrooms Amanita phalloides or verna

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Shock liver (ischemic hepatitis)

• prolonged period of systemic hypotension (such as
  following a cardiac arrest or patients with
  severe heart failure)
• exceeding 1000 IU/L or 50 times the upper limit
  of normal
• concomitant deterioration of renal function

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Wilson's disease 

• younger than 40 y/o
• concomitant hemolytic anemia

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Predominantly cholestatic pattern 

• First step obtain a right upper quadrant
  ultrasound

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Extrahepatic cholestasis 

• Presence of biliary dilatation
• Choledocholithiasis
• CT (head of the pancreas)
• ERCP (ampulla of Vater)
• Gold standard
• removal of common bile duct stones and the
  placement of stents
• Transhepatic cholangiography
• MRCP
• Malignant causes
• primary sclerosing cholangitis
• Chronic pancreatitis uncommonly
• AIDS cholangiopathy

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Intrahepatic cholestasis 

• Absence of biliary dilatation
• False negative (scarring prevent from)
• partial obstruction of the common bile duct
• cirrhosis
• primary sclerosing cholangitis
• Drug
• Primary biliary cirrhosis
• Primary sclerosing cholangitis (in 65 percent of
  patients with PSC, both intra- and extrahepatic
  ducts are involved )
• Other total parenteral nutrition,
  non-hepatobiliary sepsis, benign post-operative
  cholestasis, and a paraneoplastic syndrome dot to
  different malignancies

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