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Abnormal LFT's

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causes and interpreitations of abnormal liver function tests

causes and interpreitations of abnormal liver function tests

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Abnormal LFT's Abnormal LFT's Presentation Transcript

  • Abnormal LFT’s Dr E M Said
  • why do we check LFT’s?
    • Well person screening
    • To investigate unexplained symptoms
    • For pre-operative or base line assessment
    • For investigation of suspected liver disease
  • What are LFT’s?
    • The term “LFTs” is imprecise…
    • Many of the tests reflecting the health of the liver are not direct measure if its function .
    • Normal test values are arbitrarily defined as those occurring within two standard deviation of the the mean i.e 5% of of healthy individuals will have abnormal LFTs
          • According to the American Gastroenterological Association (AGA), 1 to 4 percent of the asymptomatic population may have elevated serum liver chemistries.
          • This is consistent with the usual definition .
  • Remember….
    • abnormal LFTs often,but not always,indicate something wrong with the liver.
    • The commonly used LFTs may be abnormal even in a healthy liver.
    • Normal LFTs do not always mean that the liver is normal.
  • approach
    • History:
    • The most important part in evaluation of a patient with abnormal LFTs
  • approach
    • History:
    • The most important part in evaluation of a patient with abnormal LFTs
    • Exposure to any chemicals
    • Use of any medications
    • The duration of abnormal LFTs
    • The presence of accompanying symptoms e.g jaundice ,artheralgia,Wt loss fever,pruritus
  • approach
    • History:
    • The most important part in evaluation of a patient with abnormal LFTs
    • Physical examination:
    • ?finding suggestive CLD
  • approach
    • History:
    • The most important part in evaluation of a patient with abnormal LFTs
    • Physical examination:
    • ?finding suggestive CLD
  • approach
    • History:
    • The most important part in evaluation of a patient with abnormal LFTs
    • Physical examination:
    • ?finding suggestive CLD
    • Lap testing:
    • evaluate the overall pattern
  • LFT profile :
    • Bilirubin
    • Total protein
    • ALT
    • ALP
    • Gamma GT
    • Albumin
    • Prothrombin time
  • Patterns of abnormal LFT’s
    • Sole or combined elevation
    • acute or chronic
    • Predominantly Hepatocellular
    • Predominantly cholestatic
  • Bilirubin
    • Produced by haemoglobin catabolism
    • Isolated hyper bilirubinaemia occurs in tow settings:
    • Over production
    • Impaired uptake,conjugation or excretion
  •  
  • ALT
    • cytoplasmic enzyme that is predominantly hepatic in origin
    • Lesser quantities are found in the kidneys, heart, and skeletal muscle
    • Injury or disease of the liver parenchyma cause a release of the enzyme into the bloodstream
    • Generally, most ALT elevations are caused by liver dysfunction
  • Typical ALT Values in Disease
  •  
  • ALP
    • Largely originate from the liver,mainly cells lining biliary ducts or membranes adjoining the bile canaliculi,and bones
    • Marked increase is typical of cholestasis (often with raised GGT)
    • Variety of bone disorders (usually without raised GGT)
    • Isoenzymes may be useful for distinguishing these sources
  •  
  •  
  • Gamma GT
    • Found in the hepatocytes and biliary epithelial cells.
    • Sensitive in detecting hepatobiliary disease but limited by lack of specificity
    • Best used to evaluate elevation of other enzymes
    • High GGT with otherwise normal liver should not lead to exhaustive work up for liver disease
  • Gamma GT
    • Found in the hepatocytes and biliary epithelial cells.
    • Sensitive in detecting hepatobiliary disease but limited by lack of specificity
    • Best used to evaluate elevation of other enzymes
    • High GGT with otherwise normal liver should not lead to exhaustive work up for liver disease
    Twofold elevation with AST:ALT ratio2:1suggest alcohol abuse
  •  
  • Albumin
    • Albumin is synthesised in the liver
    • Albumin has a plasma half-life of three weeks; therefore, serum albumin concentrations change slowly in response to alterations in synthesis.
    • In practice, patients with low serum albumin concentrations and no other LFT abnormalities are likely to have a nonhepatic cause for low albumin, such as proteinuria or an acute or chronic inflammatory state.
  • Prothrombin time
    • Not usually included in the LFTs panel
    • abnormal PT prolongation may be a sign of serious liver dysfunction.
    • An elevated PT can result from a vitamin K deficiency ,a trial of vitamin K injections is the most practical way to exclude vitamin K deficiency in such patients.
  • Predominantly Hepatocellular
    • Usually ALT>ALP
    • Alcoholic hepatitis
  • Predominantly Hepatocellular
    • Usually ALT>ALP
    • Alcoholic hepatitis
    • Typically AST:ALT is 2:1
    • AST rarely exceed300
  • Predominantly Hepatocellular
    • Usually ALT>ALP
    • Alcoholic hepatitis
    • Viral hepatitis
  • Predominantly Hepatocellular
    • Usually ALT>ALP
    • Alcoholic hepatitis
    • Viral hepatitis
    Aminotransferase>500 ALT greater or equal AST
  • Predominantly Hepatocellular
    • Usually ALT>ALP
    • Alcoholic hepatitis
    • Viral hepatitis
    • Toxic hepatitis
    • Shock liver(ischemic hepatitis)
  • Predominantly Hepatocellular
    • Usually ALT>ALP
    • Alcoholic hepatitis
    • Viral hepatitis
    • Toxic hepatitis
    • Shock liver(ischemic hepatitis)
    exceeding1000IU/L Or 50x upper limit of normal
  • Predominantly Hepatocellular
    • Usually ALT>ALP
    • Alcoholic hepatitis
    • Viral hepatitis
    • Toxic hepatitis
    • Shock liver(ischemic hepatitis)
    • Wilson disease
    • Autoimmune hepatitis
  • Copyright ©2003 BMJ Publishing Group Ltd. Limdi, J K et al. Postgrad Med J 2003;79:307-312 Suggested algorithm for evaluating raised transaminases
  • Predominantly cholestatic
    • Usually ALP>ALT
    • 1 st determine intra or extrahepatic
    • Distinction may not be straightforward
    • 1 st step is Ultrasound
    • biliary dilatation extrahepatic cholestasis
    • no dilatation intrahepatic cholestasis
    • False negative in partial obstruction,cirrhosis or PSC
  • extrahepatic cholestasis
    • Choledocholithiasis
    • Malignant causes:
    • Pancreatic,gall bladder,ampullary and cholangiocarcinoma
    • Hilar lymphadenopathy
    • Chronic pancreatitis
    • AIDS cholangiopathy
  • intrahepatic cholestasis
    • Drug induced
    • Primary biliary cirrhosis
    • Primary sclerosing cholangitis
    • Other causes include:
    • Sepsis,postoperative,paraneoplastic,
    • thyroid cancer,Hypernephroma & prostate cancer
  • Copyright ©2003 BMJ Publishing Group Ltd. Limdi, J K et al. Postgrad Med J 2003;79:307-312 Suggested algorithm for evaluating a raised ALP
  • The role of liver biopsy
    • Most patients with abnormal LFTs with suspected etiologic factors for liver disease are identified by history taking, physical examination, further blood tests, and imaging
    • In patients with unexplained LFTs elevations, a liver biopsy may be helpful to identify the cause of liver disease
    • The decision to perform a liver biopsy must balance the possible risks of the procedure (eg, discomfort, bleeding, peritonitis, pneumothorax) with the potential benefits
  •