Liver dance: The steps in diagnosis of abnormal liver tests

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How to understand and evaluate abnormal liver enzymes.

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Liver dance: The steps in diagnosis of abnormal liver tests

  1. 1. LiverDance:The Steps in Diagnosis of Abnormal Liver Tests Patricia L. Raymond MD FACG Rx For Sanity LiverDance
  2. 2. LiverDance
  3. 3. LiverDance
  4. 4. Pretest• What are “Liver Function Tests” verses “Liver Tests”?• What does SGOT/SGPT ratio tell you about the etiology of the liver damage?• What about AP out of proportion to TA elevation?• Do you know how to calculate discriminant function? What do you do with it? LiverDance
  5. 5. LiverDance
  6. 6. What we’ll cover today…  Interpreting liver tests  Alphabet soup © 2010 Patricia Raymond www.RxForSanity.com 888/437-7286 www.YourHealthChoice.net 888- 4 Dr Pat 6 Some specific diseases www.ColonJoke.com  What we won’t cover: Treatment LiverDance
  7. 7. The Dance of the Liver Tests Determine “Style” based on labs Directed History © 2010 Patricia Raymond www.RxForSanity.com 888/437-7286 Directed Physical www.YourHealthChoice.net www.ColonJoke.com 888- 4 Dr Pat 6 More Labs Imaging studies or biopsy LiverDance
  8. 8. First Step:Hepatitic or Cholestatic? Hepatitic  Cholestatic Viral  Primary Biliary Cirrhosis Alcoholic (PBC) NASH  Primary Sclerosing Autoimmune Cholangitis (PSC)  Structural Obstruction Hemochromatosis  Drug Induced Alpha-1 Antitrypsin Wilson’s Disease Drug Induced LiverDance
  9. 9. Hepatitic or Cholestatic:How Do You Know? Hepatitic  Cholestatic SGOT/AST  Alkaline SGPT/ALT Phosphatase (ALP)  GGTP•If liver tests 3-5x normal,“most likely”; exceptions  5’ Nucleotidaseoccur LiverDance
  10. 10. Do Not Use the Term “LiverFunction Tests” (LFTs) Albumin Cholesterol © 2010 Patricia Raymond www.RxForSanity.com 888/437-7286 Bilirubin www.YourHealthChoice.net www.ColonJoke.com 888- 4 Dr Pat 6 Prothrombin time Low platelet count in correct setting is suggestive of portal hypertension LiverDance
  11. 11. LiverDance
  12. 12. Second Step:History Appropriate to Lab StyleHepatitic Lab Values Viral Hepatitis: Transfusions, tattoos, IVDA, multiple sexual partners (>6/yr © 2010 Patricia Raymond www.RxForSanity.com www.YourHealthChoice.net www.ColonJoke.com 888/437-7286 888- 4 Dr Pat 6 considered high risk), travel, work in day care or preschool, homosexuality Alcohol Induced: Precise ethanol intake NASH: Diabetes, hyperlipidemia LiverDance
  13. 13. © 2010 Patricia Raymond www.RxForSanity.com 888/437-7286 www.YourHealthChoice.net 888- 4 Dr Pat 6 www.ColonJoke.com LiverDance
  14. 14. LiverDance
  15. 15. Second Step:History Appropriate to Lab StyleHepatitic Lab Values Autoimmune: Amenorrhea, diabetes, thyroid disease, vitiligo, arthritis © 2010 Patricia Raymond www.RxForSanity.com 888/437-7286 Hemochromatosis: FHx, diabetes, arthritis, www.YourHealthChoice.net www.ColonJoke.com 888- 4 Dr Pat 6 impotence, FHx “early MI” A1AT: FHx, neonatal jaundice Wilson’s: FHx, personality changes, bone wasting, Fanconi’s syndrome, hemolytic anemia Drug Induced: Careful drug history LiverDance
  16. 16. Second Step:History Appropriate to Lab StyleCholestatic PBC: Itching, Worse at noc and on palms/soles, FHx connective tissue disease, Raynaud’s, © 2010 Patricia Raymond www.RxForSanity.com 888/437-7286 www.YourHealthChoice.net 888- 4 Dr Pat 6 sicca, GERD, xanthelasma www.ColonJoke.com PSC: Itching, Sx of IBD (Ulcerative Colitis) Structural: Hx biliary surgery, abdominal pain/fever, acholic stool Drug Induced: Careful drug history LiverDance
  17. 17. “I just drink one beer a day.” LiverDance
  18. 18. Step Three:Let’s Get Physical Liver size and consistancy, palpable spleen or gallbladder Spider nevi, palmar erythema, gynecomastia, caput medusaePatricia Raymond © 2010 www.RxForSanity.com 888/437-7286 Dupuytrens contractures, parotid gland enlargement, www.YourHealthChoice.net www.ColonJoke.com 888- 4 Dr Pat 6 and testicular atrophy An enlarged left supraclavicular node (Virchows node) or periumbilical nodule (Sister Mary Josephs nodule) Assessment for ascites Xanthelasmas Kaiser-Fleisher Rings LiverDance
  19. 19. Step Four:Let’s order more labsHepatitic: Hepatitis profile (incl HBsAb, HBsAg, HBcAb), HCV Ab, Fe, TIBC © 2010 Patricia Raymond www.RxForSanity.com www.YourHealthChoice.net www.ColonJoke.com 888/437-7286 888- 4 Dr Pat 6 Second round: ANA, ceruloplasmin, AIAT phenotype, AFPCholestatic: AMA, ANA, early ultrasound to image liver LiverDance
  20. 20. Just Say NOto CAT scans in liver pathology © 2010 Patricia Raymond www.RxForSanity.com 888/437-7286 www.YourHealthChoice.net 888- 4 Dr Pat 6 www.ColonJoke.com LiverDance
  21. 21. A Word on Imaging Studies: Ultrasound RUQ  Economical  Liver texture, bile duct diameter, stones, ascites, liver/ size, masseswww.RxForSanity.com spleenPatricia Raymond © 2010 www.YourHealthChoice.net 888/437-7286 888- 4 Dr Pat 6 www.ColonJoke.com  Best for HCC screening CT- masses, not too good for bile duct ERCP/MRCP- best image of biliary tree Liver/Spleen scan  Defines coloid shift, size- not too useful LiverDance
  22. 22. © 2010 Patricia Raymond www.RxForSanity.com 888/437-7286 www.YourHealthChoice.net 888- 4 Dr Pat 6 www.ColonJoke.com LiverDance
  23. 23. Step Five (Last):The Liver Biopsy Invasive technique with significant complications Gold standard in liver diagnosis © 2010 Patricia Raymond www.RxForSanity.com www.YourHealthChoice.net 888/437-7286 888- 4 Dr Pat 6  Unclear etiology despite tests www.ColonJoke.com  Exclude other dx prior to rx with significant SE  Obtain tissue for diagnosis (Fe, Cu, neoplasm)  Obtain tissue for “staging” (HCV, NASH) LiverDance
  24. 24. LiverDance
  25. 25. Side Step: Discriminant function (4.6 * Δ PT) + bili © 2010 Patricia Raymond www.RxForSanity.com 888/437-7286 If >32, 50% mortality in 1 month www.YourHealthChoice.net www.ColonJoke.com 888- 4 Dr Pat 6 Prednisone 40 mg/day for 20-40 days LiverDance
  26. 26. Baby Steps: Learn the Liver Dance  Determine “Style” based on labs  Directed History  Directed Physical  More Labs  Imaging studies or biopsy LiverDance
  27. 27. Case History #1 35 y/o male, malaise SGOT 1200 SGPT 3000 T Bil 3.2 AP 120 © 2010 Patricia Raymond www.RxForSanity.com 888/437-7286 Drinks “moderately” daily www.YourHealthChoice.net www.ColonJoke.com 888- 4 Dr Pat 6 Theraflu ingestion plus tylenol for flu What do you do now? LiverDance
  28. 28. Case History #2 70 y/o female, assymptomatic SGOT 56 SGPT 74 AP 357 T Bil 2.1 © 2010 Patricia Raymond www.RxForSanity.com 888/437-7286 Nocturnal pruritis www.YourHealthChoice.net www.ColonJoke.com 888- 4 Dr Pat 6 LiverDance
  29. 29. Case History #3 56 y/o male, executive, assymptomatic SGOT 70 SGPT 85 © 2010 Patricia Raymond www.RxForSanity.com 888/437-7286 Modest EToH (Social) www.YourHealthChoice.net www.ColonJoke.com 888- 4 Dr Pat 6 Extensive tattoos in past LiverDance
  30. 30. Case History #4 80 y/o female, painless jaundice SGOT 200 SGPT 350 AP 300 T Bil 12 © 2010 Patricia Raymond www.RxForSanity.com 888/437-7286 Weight loss, acholic stools www.YourHealthChoice.net www.ColonJoke.com 888- 4 Dr Pat 6 LiverDance
  31. 31. Case History #5 48 y/o female, assymptomatic SGOT 55 SGPT 47 AP nl T Bil nl © 2010 Patricia Raymond www.RxForSanity.com 888/437-7286 Mild obesity www.YourHealthChoice.net www.ColonJoke.com 888- 4 Dr Pat 6 LiverDance
  32. 32. LiverDance
  33. 33. Case History #6 35 y/o male, assymptomatic SGOT 55 SGPT 45 AP nl T Bil nl © 2010 Patricia Raymond www.RxForSanity.com 888/437-7286 Moderate alcohol intake www.YourHealthChoice.net www.ColonJoke.com 888- 4 Dr Pat 6 Premature MI in relatives LiverDance
  34. 34. Stuff to put on your reading list: Clinical presentation of autoimmune hepatitis and appropriate management Indications for treatment of chronic hepatitis C © 2010 Patricia Raymond www.RxForSanity.com 888/437-7286 Clinical presentation and management Gilbert’s www.YourHealthChoice.net www.ColonJoke.com 888- 4 Dr Pat 6 syndrome Some medications that may cause abnormal liver tests Clinical presentation and diagnostic approach to Budd-Chiari syndrome LiverDance
  35. 35. Alphabet Soup LiverDance
  36. 36. Hepatitis A Enteric HAV vaccination in :  Military personnel· Food handlers· Injection drug users, Patricia Raymond © 2010 Travellers to endemic regions (essentially www.RxForSanity.com www.YourHealthChoice.net 888/437-7286 888- 4 Dr Pat 6 anywhere outside ofwww.ColonJoke.com North America, Western Europe and Japan)  Occupational risk including healthcare workers, employees of mental health facilities and sewage workers, consumers of high-risk foods (e.g. raw shellfish) Patients with chronic liver disease - especially chronic hepatitis C - increased risk for fulminant hepatitis or death with HAV superinfection. LiverDance
  37. 37. Hepatitis A Most HAV infections acquired in childhood are subclinical and anicteric, yet antibodies to the virus persist for life and provide immunity to further infection. In adults, Patricia Raymond © 2010 75 to 95% of www.RxForSanity.com are symptomatic, with infections 888/437-7286 jaundice in the majoritywww.YourHealthChoice.net of cases. Fulminant 888- 4 Dr Pat 6 hepatic failure is rare but increases over the age of 40, and www.ColonJoke.com possibly in the context of underlying chronic liver disease. In some individuals, HAV causes a biphasic illness with a second bout of jaundice and cholestasis six to 12 weeks after the primary infection. Chronic HAV infection does not occur and liver enzymes are almost always normal within six months of infection. LiverDance
  38. 38. LiverDance
  39. 39. Hepatitis B Antigens HBsAg = presence of the virus HBcAg = not detected in blood HBeAg = correlates with the viral replication and infectivity © 2010 Patricia Raymond www.RxForSanity.com 888/437-7286 www.YourHealthChoice.net 888- 4 Dr Pat 6 www.ColonJoke.com Antibodies anti-HBs = antibodies to the surface anti-HBc = antibodies to the core can be either IgM (acute) or IgG (chronic) anti-HBe = antibodies to e and indicates low infectivity and probable recovery LiverDance
  40. 40. LiverDance
  41. 41. Hepatitis BExtra-Hepatic Associations :associated with hepatitis Bantigen/antibody complexes.Polyarteritis - usually involves medium and small arteries, appearsearly © 2010 Patricia Raymond www.RxForSanity.com 888/437-7286 www.YourHealthChoice.net 888- 4 Dr Pat 6 www.ColonJoke.comGlomerulonephritis - largely in children, liver disease is usually mildPolymyalgia rheumatica - usually in older personsEssential mixed cryoglobulinemia - sometimes only a test tubefindingGuillain-Barre syndromeMyocarditis LiverDance
  42. 42. LiverDance
  43. 43. Hepatitis C: Acute Very mild and often not clinically apparent. Less than 15% of all cases of acute hepatitis in the USA.  Only 2010 Patricia Raymond 25% of persons are jaundiced. 888/437-72866 © about 15 - www.RxForSanity.com www.YourHealthChoice.net 888- 4 Dr Pat  Antibodies to hepatitis C may takewww.ColonJoke.comup to three months to detect .  Early diagnosis may be difficult. About 20% of persons with acute hepatitis C fully recover and are felt to clear the virus 80% develop some form of chronicity.  Twenty-five percent of patients with chronic hepatitis will develop cirrhosis after 20 years  Of these, 5% will develop liver cell cancer and 5% decompensated cirrhosis. LiverDance
  44. 44. Hepatitis C Chronic hepatitis C infection causes chronic immune stimulation and autoimmune diseases are more frequent in hepatitis C. AutoimmuneRaymond © 2010 Patricia diseases may be seen either as presenting www.RxForSanity.com 888/437-7286 conditions or in association with hepatitis C.888- 4 Dr Pat 6 www.YourHealthChoice.net www.ColonJoke.com Diabetes Mixed cryoglobulinemia Thyroiditis Erythema nodosum Erythema multiforme Glomerulonephritis Hypothyroidism Lichen planus Polyarteritis Urticaria Porphyria cutanea tarda Polymyalgia B-cell lymphoma Mooren corneal ulcers LiverDance
  45. 45. © 2010 Patricia Raymond www.RxForSanity.com 888/437-7286 www.YourHealthChoice.net 888- 4 Dr Pat 6 www.ColonJoke.com LiverDance
  46. 46. Hepatitis D Unique incomplete virus Requires hepatitis B virus (HBV) for its replication  The©RNA genome is covered by an outer coat of 888/437-72866 B 2010 Patricia Raymond www.RxForSanity.com www.YourHealthChoice.net hepatitis 888- 4 Dr Pat surface antigen. www.ColonJoke.com Endemic in certain regions including the Mediterranean basin, the Balkan peninsula, the former Soviet Union, parts of Africa and the Middle East and the Amazon basin of South America. Spread is intrafamilial and through sexual contact. LiverDance
  47. 47. Hepatitis D: Clinical Course Depends on whether the virus was acquired as  a coinfection with hepatitis B © 2010 Patricia Raymond www.RxForSanity.com 888/437-7286  in acute self-limited hepatitis although fulminant hepatitis and www.YourHealthChoice.net www.ColonJoke.com 888- 4 Dr Pat 6 death are well described.  a superinfection in an individual with a previously established chronic HBV infection.  typical course is one of a rapidly progressive chronic hepatitis. LiverDance
  48. 48. Hepatitis E Self-limited acute form of viral hepatitis that is typically spread by fecally contaminated water. Endemic Patriciadeveloping www.RxForSanity.com © 2010 in Raymond countries 888/437-7286  The most common cause of acute viral hepatitis worldwide, it is www.YourHealthChoice.net www.ColonJoke.com 888- 4 Dr Pat 6 virtually unheard of in North America. Rare cases have been described in travellers returning from endemic regions. The clinical hallmark of HEV infection is its extremely high mortality rate when infection occurs in pregnancy, particularly in the third trimester. No HEV vaccine is yet available. LiverDance
  49. 49. © 2010 Patricia Raymond www.RxForSanity.com 888/437-7286 www.YourHealthChoice.net 888- 4 Dr Pat 6 www.ColonJoke.com LiverDance
  50. 50. Medication Almost any medication can cause an elevation of liver enzymes. Common ones include nonsteroidal anti- © 2010 Patricia Raymond www.RxForSanity.com 888/437-7286 www.YourHealthChoice.net 888- 4 Dr Pat 6 inflammatory drugs, antibiotics, HMG-CoA www.ColonJoke.com reductase inhibitors, antiepileptic drugs, and antituberculous drugs. In addition to prescription medications, herbal preparations and illicit drug use may also be the cause. LiverDance
  51. 51. LiverDance
  52. 52. Herbs are safe…not Comfry Germander Pennyroyal © 2010 Patricia Raymond www.RxForSanity.com www.YourHealthChoice.net 888/437-7286 888- 4 Dr Pat 6 www.ColonJoke.com Mistletoe Kava Chapparal Ma-Huang Ephedra, Senna, Cascara LiverDance
  53. 53. NASH LiverDance
  54. 54. NASH Epidemic Risk factors: central obesity, type 2 diabetes mellitus, dyslipidemia, and metabolic syndrome 20 to 40 % of the general population © 2010 Patricia Raymond www.RxForSanity.com 888/437-7286 www.YourHealthChoice.net 888- 4 Dr Pat 6 Symptoms: most asymptomatic, rare fatigue, www.ColonJoke.com malaise, and vague right upper abdominal discomfort Dx: fat in liver (US), < 20 g alcohol daily, negative hepatitis B & C serology LiverDance
  55. 55. The liver takes a beating © 2010 Patricia Raymond www.RxForSanity.com 888/437-7286 www.YourHealthChoice.net 888- 4 Dr Pat 6 www.ColonJoke.com LiverDance
  56. 56. NASH Epidemic AST and ALT elevated in 90 %  AST/ALT ratio is less than 1  Much lower than thewww.RxForSanity.com © 2010 Patricia Raymond ratio in alcoholic hepatitis 888/437-7286 www.YourHealthChoice.net 888- 4 Dr Pat 6  Usually > 2 www.ColonJoke.com Treatment: Weight loss LiverDance
  57. 57. © 2010 Patricia Raymond www.RxForSanity.com 888/437-7286 www.YourHealthChoice.net 888- 4 Dr Pat 6 www.ColonJoke.com LiverDance
  58. 58. Wilsons Disease © 2010 Patricia Raymond www.RxForSanity.com 888/437-7286 www.YourHealthChoice.net 888- 4 Dr Pat 6 www.ColonJoke.com LiverDance
  59. 59. Wilsons Disease © 2010 Patricia Raymond www.RxForSanity.com 888/437-7286 www.YourHealthChoice.net 888- 4 Dr Pat 6 www.ColonJoke.com LiverDance
  60. 60. Wilson’s Disease Autosomal recessive defect of cellular copper export  Accumulation of copper, initially in the liver and then © 2010 Patricia Raymond www.RxForSanity.com 888/437-7286 in other tissues, particularly the brain. 888- 4 Dr Pat 6 www.YourHealthChoice.net www.ColonJoke.com  Hepatic, neurologic, hematologic, and renal impairment. Kayser-Fleischer rings in 50 to 60 % with isolated hepatic involvement, > 90 % with neurologic involvement Ceruloplasmin concentration < 20 mg/dL with Kayser- Fleischer rings is considered to be diagnostic. LiverDance
  61. 61. © 2010 Patricia Raymond www.RxForSanity.com 888/437-7286 www.YourHealthChoice.net 888- 4 Dr Pat 6 www.ColonJoke.com LiverDance
  62. 62. © 2010 Patricia Raymond www.RxForSanity.com 888/437-7286 www.YourHealthChoice.net 888- 4 Dr Pat 6 www.ColonJoke.com LiverDance
  63. 63. © 2010 Patricia Raymond www.RxForSanity.com 888/437-7286 www.YourHealthChoice.net 888- 4 Dr Pat 6 www.ColonJoke.com LiverDance
  64. 64. LiverDance

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