Abnormal LFTs

Question 1

what is unconjugated bilirubinaemia a sign of?

conjugated?

Answer 1

• haemolysis/pre-hepatic jaundice
• hepatocellular disease
• biliary obstruction

Question 2

what two intracellular enzymes would you look at in LFTs?

what ratio should you look at in alcoholics?

what is the normal ratio?

what is it in alcoholics?

Answer 2

• AST/ ALT
• AST/ ALT ratio
• normally 0.8
• > 2 normally

Question 3

where can alkaline phosphatase be found?

what is the reason for them in the liver?

Answer 3

• liver
• bone
• intestine
• 1st trimester placenta
• kidney
• downregulate secretory actives of intrahepatic epithelium

Question 4

how could you tell if the ALP was raised from bone turnover or liver damage?

how would you gold standard test a patient with abnormal LFTs to establish a cause?

Answer 4

• look at GGT
• in the liver it would be elevated, in bone it would be normal
• liver biopsy

Question 5

what kind of picture would you see with hepatocellular injury?

what about cholestasis?

Answer 5

• very high AST/ ALT ratio, moderate ALP increase
• slightly elevated AST/ALT, very high ALP
• bilirubin elevated in both

Question 6

what medications might cause an isolated elevation in LFTs?

Answer 6

• NSAIDs
• Abx
• Statins
• TB meds
• AEDs
• paracetamol
• acetaminophen

Question 7

what blood tests would you do in haemochromatosis?

Answer 7

• serum iron
• TIBC/ Transferrin: Which will be normal/ low in haemochromatosis, high in IDA, carries iron
• If iron saturation is > 45% then check ferritin
• ferritin: stores iron
• liver biopsy

Question 8

what would the AST/ALT ratio be in NAFLD?

who normally gets this?

Answer 8

• AST/ALT ratio <1, not normally more than 4 fold increase
• AST/ALT increase
• fat females with diabetes

Question 9

what blood tests would you do for autoimmune hepatitis?

what would you check for Alpha1- Antitrypsin deficiency and what is the treatment? (not trick question)

Answer 9

• Anti smooth muscle Antibody (SMA)
• ANA +ve
• Serum protein electrophoresis (SPEP)
• liver biopsy
• Alpha 1 antitriptase levels, liver transplant

Question 10

what would you see in Wilsons disease?

how do you treat?

what would you see in ischaemic hepatitis?

Answer 10

• low serum caeruloplasmin
• Kayser Fleischer rings
• copper chelating agents
• Zinc
• severely elevated (50x) AST/ALT

Question 11

give examples of diseases when you see the cholestatic blood pattern?

Answer 11

• Primary biliary cirrhosis (women age 35-65, anti mitochondrial antibody)
• Primary sclerosis cholangitis (90% have IBD mainly UC)