Abnormal Liver Function Tests

1
Abnormal Liver Function Tests

• Serina Farzin-Nasab, MD
• Emory University
• Family Medicine Residency Program

2

• 3 Categories
• 1- Direct hepatocellular damage (transaminases)
•  
• 2-Cholestasis ( bilirubin, alkaline phosphates)
•  
• 3-Livers synthetic ability ( albumin, PT)

3

• Transaminitis
• Hepatocyte necrosis leads to leakage of enzyme
•  
• Hepatitis
• Toxic injury
• Ischemic injury

4

• Hep C liver cell death by apoptosis (programmed
  cell death) and by necrosis
• 1/3 pts with Hep C have persistently normal
  serum transaminases

5

• Levels of aminotransferases can rise in Severe
  muscular exertion or other muscle injuries,
  polymyositis
• Hypothyroidism

6

•  AST and ALT levels do not follow a normal
  bell-shaped distribution  
•  
•  
• AST and ALT are higher in obese pts, males
  and nonwhites ( blacks and Hispanics)

7

• Causes of Elevated ALT or AST Values in
  Asymptomatic Patients
• A) Autoimmune hepatitis
• B) Hepatitis B
• C) Hepatitis C
• D) Drugs or toxins
• E) Ethanol
• F) Fatty liver

8

• G) Growths (tumors)
• H) Hemodynamic disorder (congestive heart
  failure)
• I) Iron (hemochromatosis), copper (Wilson's
  disease) or alpha1-antitrypsin deficiency
• M) Muscle injury

9

•    Typical AST or ALT Values in Disease
•  

10
MARKERS OF CHOLESTASIS

• Cholestasis reflected in abnormal bilirubin and
  AP levels
• In acute bile duct obstruction from a gallstone,
  AST and ALT levels often reach 500 U per L or
  more in the first hours , whereas AP and GGT
  levels can take several days to rise.

11

• Elevation of GGT alone results from enzyme
  induction by alcohol or aromatic medicatios
• GGT is elevated in persons who drink 3 or more
  per day

12
Direct/conjugated hyperbilirubinemia

• Conjugated bilirubin levels do not rise until the
  liver has lost approximately half of its
  excretory ability.
• The presence of conjugated bilirubin in the urine
  ( urine dipstick), is always indicative of
  hepatobiliary disease .

13
Indirect/uncongealed Hyperbilirubinemia

• Gilbert syndrome
• Common benign inherited disorder
• Levels between 2 and 3 mg/d
• Patients develop detectable jaundice during
  acute illness or starvation

14

• Hemolysis
• Confirmed by an elevated retic count increased
  haptoglobin levels.
• In adults, no serious liver disease will
• cause elevation of indirect bili alone
  without a concurrent rise in direct bili levels.

15
AP

• Elevated levels are found in adolescents,
  children (secondary to bone growth), and pregnant
  women
• Women with persistently elevated AP levels
• primary biliary cirrhosis
• Confirmed by a serum antimitochondrial antibody
  test

16
Hepatic Cause of elevated AP

• Hepatocellular disease (usually lt3-fold increase)
• Alcoholic hepatitis
• Viral hepatitis
• Fatty infiltration of liver
• Cirrhosis

17
Hepatic Cause of elevated AP

• Obstructive processes (usually gt3-fold increase)
• Choledocholithiasis
• Cancer of head of pancreas
• Cholangiocarcinoma
• Cholestatic hepatitis

18
Hepatic Cause of elevated AP

• Infiltrative, neoplastic, Primary or metastatic
  carcinomas (15- to 20-fold increase)
• Primary biliary cirrhosis
• Amyloidosis
• Hepatic congestion caused by heart disease
• Infectious mononucleosis

19
Hepatic Cause of elevated AP

• Medications
• Captopril
• Erythromycin
• Gold salts
• Phenothiazines
• Trimethoprimand-sulfamethoxazole
• Anticonvulsants

20

• Increased synthesis of AP in Diabetes mellitus
• 44 of patients with DM have increased AP

21
Common Non hepatic Causes of Elevated GGT

• Acetaminophen overdose
• Acute myocardial infarction
• Acute pancreatitis
• Anticonvulsants (phenytoin, phenobarbital,
• carbamazepine)

22

• Brain tumor
• Diabetes mellitus
• Hyperthyroidism
• Infectious mononucleosis
• Epilepsy

23
Albumin

• An Index of liver synthetic capacity
• Low albumin level and no other LFT
• abnormalities are likely to have a non hepatic
  cause

24
Albumin

• Non hepatic causes of low Albumin
• Inflammatory states such as burns, trauma,
• sepsis
• Active rheumatic disorders
• Severe end-stage malnutrition
• Pregnancy
• Proteinuria

25
PT

• Does not become abnormal until more than 80of
  liver synthetic capacity is lost
• Useful to be followed in acute hepatic failure
• (Factor 7 has very short half life)

26
PT

• Vitamin K deficiency
• Chronic cholestasis or fat malabsorption
• A trial of vitamin K injections ( 5 mg /day SQ x
  3 days) practical way to exclude vitamin K
  deficiency
• PT should improve within a few days

27
Ammonia

• Concentrations are much higher in the brain than
  in the blood and therefore do not correlate well
• It is not unusual for the blood ammonia to be
  normal in a patient who is in a coma from hepatic
  encephalopathy.

28
QUIZ

• Other than hepatitis, causes of elevated
• serum GGT include all of the following except
• A. Diabetes mellitus.
• B. Hypothyroidism.
• C. Brain tumor.
• D. Infectious mononucleosis.
• E. Acute myocardial infarction

29

• Answer B
• Hyperthyroidism is associated with
• elevated GTT

30
QUIZ

• The greatest increase in serum alkaline
• phosphatase is generally seen in a patient
• with which of the following conditions?
• A. Primary biliary cirrhosis.
• B. Alcoholic hepatitis.
• C. Viral hepatitis.
• D. Fatty infiltration of the liver.
• E. Cancer of the head of the pancreas

31

• Answer A
• Primary billiary cirrhosis

32
QUIZ

• In patients with viral hepatitis, the serum
  AST level is usually higher than the serum ALT
  level
• A. True.
• B. False

33

• False

34
QUIZ

• Normally, most of the total bilirubin is
  conjugated.
• A. True
• B. False

35

• False
• 70 of total Billi is non conjugated