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GI > 4- LFTs > Flashcards

4- LFTs Flashcards

1
Q

what are liver enzymes in liver biochemical tests?

A
  • alanine aminotransferase (ALT)
  • aspartate aminotransferase (AST)
  • alkaline phosphatase (ALP)
  • gamma glutamyl transferase (GGT)
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2
Q

what are liver function tests?

A
  • bilirubin
  • albumin
  • prothrombin time
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3
Q

what are transaminases?

A

same as aminotransferases = ALT & AST are main ones

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4
Q

when is ALT & AST released?

A

damage to hepatocytes

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5
Q

along with being found in liver - where else can ALT and AST be found?

A
  • ALT found in low concentrations in muscle & kidney
  • AST found in cardiac & skeletal muscles, kidney, pancreas and RBC’s
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6
Q

with ALT 50-200 = what can be causes?

A

= MASLD, chronic viral hepatitis

(can be autoimmune hepatitis, hereditary haemochromatosis, wilson’s disease, alpha 1 antitrypsin deficiency)

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7
Q

with ALT 1000 = what can be causes?

A
  • viral hepatitis
  • shocked liver (hypotension from sepsis etc→shock)
  • paracetamol overdose
  • autoimmune hepatitis
  • Budd-Chiari
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8
Q

with ALT 3000 = what can be causes?

A

drug (paracetamol) or ischaemia

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9
Q

are both ALT and AST always elevated together?

A

no, in hepatitis C virus & fatty liver ALT can be elevated and not AST
(AST is found in lots more other places so when localised inflammation might not elevate)

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10
Q

by how much does ALT rise in alcoholic hepatitis?

A

no more than 3 x upper limit of normal

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11
Q

what biochemical tests are different in acute biliary obstruction?

A

ALT increased and then later increased ALP as a result of bile duct obstruction

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12
Q

what is normal AST:ALT ratio?

A

usually <1

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13
Q

what is AST:ALT ratio in fibrosis?

A

in fibrosis >1

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14
Q

what is AST:ALT ratio in alcoholic liver disease?

A

AST 2x > ALT in alcohol related liver disease

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15
Q

what is alkaline phosphatase (ALP)?

A

biliary enzyme that is in liver, placenta and bone, kidney & intestine

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16
Q

where is alkaline phosphatase in liver?

A

present on canicular epithelia = increase bile salts leads to increased release from cell surface →marker of biliary tree irritation (blockage means rises & falls slower)

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17
Q

when does ALP in placenta increase?

A

increases 2x more than upper limit of normal which may persist for a few weeks pas delivery

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18
Q

what does ALP correlation with GGT reveal?

A

increase in ALP and GGT reveals biliary source

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19
Q

what is gamma glutamyl transferase?

A

biliary enzyme that is excreted in bile in hepatocytes & biliary epithelial cells

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20
Q

how is GGT related to alcohol?

A

it can be induced in alcohol (released)
= not definitive diagnostic of alcohol through as other reasons too
= once stop drinking, levels drop

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21
Q

what can increase release of GGT?

A
  • alcohol
  • enzyme inducing medications like anticonvulsants (phenytoin, barbiturate)
  • increase in serum liver disease
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22
Q

what is unconjugated bilirubin and causes?

A

indirect bilirubin

causes:
- haemolysis
- haematoma resorption
- gilbert’s syndrome

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23
Q

what is conjugated bilirubin and causes?

A

direct bilirubin

causes:
- biliary pathology
- hepatitis
- cirrhosis
- drug toxins
- TPN

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24
Q

what are episodes of jaundice precipitated by?

A
  • Fasting
  • Hemolysis
  • Intercurrent febrile illnesses
  • Physical exertion
  • Stress
  • Mense
25
Q

where is albumin synthesised and what’s function?

A
  • synthesised by liver
  • transports insoluble bilirubin, hormones, fatty acids
26
Q

what causes albumin synthesised?

A
  • end stage liver disease
27
Q

what is prothrombin time?

A

a part of liver function test = increased prothrombin time related to decreased synthesis of clotting factors (fibrinogen II, V, VII, X)

  • used to assess coagulation pathways
28
Q

what is example of acute liver injury that increases prothrombin time?

A
  • Massive hepatocellular necrosis (acute toxic or viral hepatitis) →↑ prothrombin time
  • Prothrombin time can be monitored in order to assess the risk of acute liver failure.
29
Q

what effect does chronic liver disease have on prothrombin time?

A

long PT

30
Q

what viruses are involved in liver screen?

A

viral hepatitis serology:
- Hep B & C serology
- hep A & E

other viruses:

  • epstein barr virus (EBV)
  • cytomegalovirus (CMV)
  • Herpes SImplex Virus (HSV)
31
Q

what autoimmune markers are checked for in liver screen?

A
  • antinuclear antibodies
  • anti-smooth muscle antibodies
  • anti-liver/kidney microsomal antibodies type 1 (anti-LKM1)
  • Antimitochondrial antibody (AMA)
  • Immunoglobulins = IgG, IgM and IgA
32
Q

what haematinics is checked for in liver screen?

A
  • TSATs> 45% for women or 55% for men (transferrin saturation)
  • Ferritin >200ng/ml or >300ng/ml for men
33
Q

what are tested for in liver screens?

A
  • viral hepatitis serology
  • other viruses
  • autoimmune markers
  • haematinics
  • caeruloplasmin
  • alpha 1 antitrypsin
34
Q

what are 3 main patterns to think about to decipher abnormal LFTs?

A
  • hepatitis →problem with liver parenchyma
  • cholestatic →problems with bile duct
  • mixed
35
Q

for autoimmune hepatitis
a) most common gender
b) symptoms
c) what age

A

a) females
b) asymptomatic or non specific symptoms
c) peaks around puberty and between 4th &6th decade

36
Q

what is involved in diagnosis of autoimmune hepatitis?

A
  • hepatitic LFTs
  • increased IgG
  • autoimmune profile →either type 1 (anti-SMA, ANA) or 2 (anti-lkm-1, antiLC1)
  • liver biopsy
37
Q

what is treatment of autoimmune hepatitis for acute and maintenance ?

A

acute = prednisolone (milder = budesonide)
maintenance = azathioprine (immunosuppressant)

38
Q

what viral infections can cause liver failure?

A
  • hepatitis A-E
  • epstein barr virus, cytomegalovirus, herpes simplex virus
39
Q

what are liver function tests in MASLD and what is MASLD?

A

MASLD = Metabolic dysfunction-associated steatotic liver disease

  • ALT is usually elevated, while AST:ALT ratio >1 suggests advanced fibrosis.
  • ALP and GGT levels may be increased.
  • Serum bilirubin and albumin levels are typically normal.
40
Q

what is onset of alcoholic hepatitis?

A

onset of jaundice and/or ascites in a patient with ongoing alcohol misuse/recent cessation

41
Q

what are assessment scores to be used in alcoholic hepatitis?

A
  • maddrey’s discriminant function = >32 correlated 45% mortality at 28day
  • glasgow hepatitis score = composite score ≥9 28 day survival much worse
42
Q

what is treatment of alcoholic hepatitis?

A

prednisolone can be beneficial in short term mortality but not for any longer than that = treatment depends on individual clinicians

  • can use neutrophil lymphocyte ratio to see if will benefit
43
Q

what are cholestatic liver test?

A

= tests to assess liver function & identify conditions associated with impaired bile flow from the liver

44
Q

what is colicky pain often associated with?

A

gallstones

45
Q

what is MRCP?

A

MRCP stands for Magnetic Resonance Cholangiopancreatography. It is a non-invasive imaging technique that uses magnetic resonance imaging (MRI) to visualize the bile ducts, pancreas, and pancreatic ducts. MRCP is particularly useful in evaluating the biliary tree

46
Q

what is primary biliary cholangitis?

A

a chronic autoimmune liver disease characterized by progressive destruction of the small bile ducts within the liver
- associated with systemic sclerosis

47
Q

what are symptoms & signs of primary biliary cholangitis?

A

Symptoms:
- Itch
- Lethargy
- Dry eyes

Signs:
- Xanthesalma and xanthomas

48
Q

what is pathophysiology of primary biliary cholangitis?

A
  • coordinated T&B cell mediated autoimmune cascade with T cell mediated BEC injury
  • loss of protective bicarbonate rich umbrella around BECs and gradua loss of bile ducts
  • progressive inflammation & biliary fibrosis
  • cholestasis
49
Q

what is treatment of primary biliary cholangitis?

A

1st line: Ursodeoxychloic acid

50
Q

what is primary sclerosing cholangitis?

A

chronic inflammatory liver disease characterized by progressive inflammation and fibrosis of the bile ducts both inside and outside the liver

51
Q

what is seen on MRCP for diagnosis of primary sclerosing cholangitis?

A

= multiple segmental strictures with dilated intrahepatic and extrahepatic ducts

52
Q

what is seen on biopsy for diagnosis of primary sclerosing cholangitis?

A

ductopenia, bile duct proliferation, and periductal fibrosis, with an onion-skin fibrosis and nodular fibrous scars

53
Q

what is treatment for primary sclerosing cholangitis?

A

no treatment →try manage stricture, survey for gallbladder and colorectal cancer in IBD survey

54
Q

what mostly causes mixed pattern of LFTs?

A

drugs! - any drugs but commonly
- Hepatitis (isoniazid, phenytoin, methyldopa)
- Cholestasis (augmentin, ocpill, androgens)
- Steatosis (TPN, methotrexate)

55
Q

what are other causes of mixed LFTs?

A
  • hereditary haemochromatosis (excess iron deposition, high ferrin & transferrin)
  • wilsons disease (excess copper deposition, low ceruplasmin liver screen)
  • budd chiari (hepatic vein occlusion, seen on doppler US)
  • pregnancy (cholestasis or acute fatty liver)
56
Q

what are principles of investigation for abnormal LFTs?

A
  • history
  • examination
  • liver screen & AUSS
    = use pattern to develop likely aetiology
57
Q

generally for acute hepatitis, are the following increased, decreased or normal
a) ALT
b) ALP
c) GGT
d) bilirubin

A

a) increased
b) normal or increased
c) normal or increased
d) increased

58
Q

generally for chronic hepatitis, are the following increased, decreased or normal
a) ALT
b) ALP
c) GGT
d) bilirubin

A

a) normal or increased
b) normal or increased
c) normal or increased
d) normal or increased

59
Q

generally for cholestatic, are the following increased, decreased or normal
a) ALT
b) ALP
c) GGT
d) bilirubin

A

a) normal or increased
b) increased
c) increased
d) normal or increased

GI (56 decks)

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