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LABORATORY TESTS AND DIAGNOSTIC PROCEDURES IN
LIVER DISEASE

• Manthani J. Reddy M.D., M.P.H
• Department of Family Medicine Community Health
• Mount Sinai Hospital Chicago

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Diagnostic Procedures

• Hepatic Scintiscanning (IDA Agents)
• Ultrasound
• CT
• MRI
• ERCP/PTHC
• Liver Biopsy

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Hepatic Scintiscanning

• the IDA Agents
• Acute Cholecystitis
• Biliary leaks
• Biliary-Enteric shunts
• Choledochal cysts

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MRI

• Hepatic metastases
• Vascular lesions, e.g., hemangioma
• Hepatic and portal vein
• Iron overload

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Computed Tomography - CT

• Hepatic lesions
• Jaundice
• Budd-Chiari syndrome
• Iron overload

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Ultrasound

• Hepatic lesions
• Ascites
• Gallstones
• Jaundice

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Lab Tests

• Liver Function Tests
• Special Tests
• Alpha-1 Antitrypsin
• HFE (Hemochromatosis Gene)
• Ceruloplasmin
• Serum alphafetoprotein
• Breath Tests
• Urine Test (Bilirubin, Urobilinogen)

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Liver Function Tests LFT

• Liver Function Tests
• Galactose clearance test
• Aminopyrine clearance test
• Serum Albumin
• Bilirubin
• PT/INR

• Liver Dysfunction Tests
• AST
• ALT
• GGT
• ALP
• LDH

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Serum Bilirubin (0.2 1.2)

• Indirect, direct, delta
• Isolated hyperbilirubinemia
• Prognostic Indicator
• Alcoholic hepatitis
• Halothane hepatitis
• PBC

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Alcoholic Hepatitis

• Discriminant Function Value
• Prothrombin time Control x 4.6
• PLUS
• Serum bilirubin (in mg/dl)
• Value gt 32, mortality 50!

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Serum Bilirubin (direct-total ratio)
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PT/INR

• PT/INR (I, II, V, VII, X)
• Vitamin K dependent factors (II, VII, IX, X)
• PT is a good index of a liver function
• If PT is prolonged due to vitamin K deficiency,
  injection of vitamin K will result in 30
  correction in 24hrs.

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Albumin

• Acute VS. Chronic
• Half life approximately 3 weeks
• Decrease in Albumin usually indicates Liver
  disease of more than 3 weeks duration
• Always consider other causes of Hypoalbuminimia

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Serum Globulins
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GGT

• Isolated elevation most common with alcohol (DM,
  post MI drugs)
• GGT ALP ratio gt5 favors alcoholic Liver disease
• GGT is done to confirm ALP elevation from Liver
  source

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Serum-5 Nucleotidase Leucine Aminopeptidase
Parallel
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AST ALT

• Markers of Parenchymal damage
• AST (Cytoplasm Mitochondria) Liver, Heart,
  Muscle, Brain, Kidney
• ALT (Cytoplasm) more specific for Liver
• AST ALT ratio of gt2 indicative of alcoholic
  disease
• ALT AST ratio 1 (Viral Hepatitis)
• ALT testing is done to confirm AST elevation

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Three Causes of Unexplained ALT (SGPT)
Elevations

• Muscle Disease/Injury (CPK)
• Thyroid Dysfunction (TSH)
• Celiac Sprue (Anti-endomysial antibody)

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Serum Aminotransferase Levels Exceeding 500 IU/L

• Acute viral hepatitis
• Drug or toxic liver injury
• Ischemic hepatitis
• Severe C.A.H.
• CBD stone
• Budd Chiari and V.O.D.
• Acute Fatty Liver of Pregnancy
• HELLP Syndrome

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Serum Alkaline Phosphatase Sources

• Liver
• Bone
• Small Intestine
• Placenta
• Other, e.g., Regan isoenzyme
• CHF, CRI, DM, Hyperthyroidism Albumin use
• ALP ? 1000 with normal bili suggest
  Granulonatous/ infiltrative disease

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Elevated ALK Phos (ALP) Algorithmic Approach R/o
Physiological Causes (F lt 20, M lt 30,
Pregnancy/Post Partum)
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Abnormal liver function test results repeat test
and confirm that liver dysfunction is the source
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3. Predominantly ? transaminases
Hepatitis A or B or C infection
Hepatitis profile
Positive

• a1 anti trypsin deficiency usually chronic
  hepatitis picture

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• Predominantly
• ? alkaline phosphatase

CGT
Normal
Evaluate for bone disease
Liver biopsy is indicated for diagnosis of
Hemochromatosis, Autoimmune hepatitis, Wilsons
diseases, PBC, PSC and NASH
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NASH / NAFLD

• Definition Non alcoholic steatohepatitis (NASH)
  is the term used to describe the distinct
  clinical entity in which patients lack of history
  of significant alcohol consumption and have liver
  biopsy findings indistinguishable from alcoholic
  hepatitis
• NAFLD Fat ? steato hepatitis ? Fibrosis/Cirrhosis

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Epidemiology of NASH

• Present in 7-9 of patients undergoing liver
  biopsies in the USA
• 1-2 of patients undergoing liver biopsies in
  Japan
• Majority of cases occur between ages of 40 and 60
  years
• Women account for 65-83 of patients NASH
• Account for 11 of referrals to an urban liver
  clinic

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NASH Major Associated Conditions

• Diabetes (Type 2) (35 - 75)
• Obesity (70 - 100)
• Hyperlipidemia (20 - 80)

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NAFLD is Part of the Matabolic Syndrome Called
Syndrome X

• Obesity
• Hyperinsulinemia
• Insulin Resistance

Hypertriglyceridemia Hypertension Diabetes
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Other Conditions Associated with NASH

• Toxins
• Metabolic Disorder

• Abdominal Surgery
• Miscellaneous

• Drugs

• Glucocorticoids
• Synthetic estrogens
• Amiodarone

• Tamoxifen
• Perhexilene maleate
• Isoniazid

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Natural History of NASH

• Pooled date from 3 studies. 28 patients with
  clinical and histologic follow-up over 1-9 yrs

NASH is likely a major cause of Cryptogenic
Cirrhosis
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Clinical Features of NASH

• Symptoms
• Asymptomatic
• Fatigue
• RUQ Discomfort or Pain

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Laboratory Features of NASH

• ALT and AST 2 to 4 fold elevated in most patients
• Alk phos mildly elevated in a third of patients
• Albumin, PT, bilirubin most often normal
• Serum ferritin elevated in half the patients

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Treatment of NASH

• Weight loss, control of diabetes hyperlipidemia
• Vitamin E
• Ursodeoxycholic acid
• Metformin
• Betaine
• Phlebotomy

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