Abnormal Liver Function Tests and Hepatic Neoplasms

Question 1

AST/ALT

Answer 1

Catalyze transfer of alpha amino groups from aspartate to generate oxalacetic acid (AST) and from alaine to generate ALT

Alny inflammation or destruction

Vit B6 def will dec ALT activity so may have higher AST than ALT

Also present in other places so could be myosisits or hemolysis

Question 2

Alk phos
GGT
Bilirubin

Answer 2

Cell trnapsort…obstruction (cholestasis)….elevation can occur with bony tunroever and in pregnancy as well…add in children

GGT not specific but if both alk phos and GGT, then from liver and not bone

Must be conjugated by hepatocytes…hepatocellular and cholestatis damage

Question 3

Etiologies of elevated enzymes

Answer 3

Mold to mod elevations of AST/ALT can be caused by both acute and chornic

Chronic more likely if low albukim, inc PT or INR and more Alk phos elevation

If over 1000, then acute viral hep, ischemic hepatopathy or drug/toxin exposure….although other LFTs are normla, massive haptic necrosis can have low albumin and elevated PT/INR

If pt has no other abnormal LFTs besides alk phos, think non-hepatic etiology….children and adlescents, over 60, group O and B, 3rd trimester is normal

Question 4

Acute viral hepatitis

Answer 4

Prodromal

Fever more with A or E…liver becomes enlarged…can get jaundice….AST and ALT elevated during prodrome…then bilirubin with both peaking at same time

Recorver is mos with A and E…more common chronic in hep C….Hep B - polyarteritis nodsa, membranous neprhopathy and aplastic anemia

Hep C - mixed cryoglobulinemia and membranoproliferative glomeruloneprhitis

Question 5

Alcohol hep
NAFD
Hemochromatosis

Answer 5

Acute - over 15 pint years….sx immediately after yse…hepatic enceph and ascitis….elevated transminases with AST/ALT ratio of over 2

Chronic - steatosis, steatohep and cirrhosis…AST/ALT over 2

NAFLD - hepatic fat acumulation….can progress to inflammation, fibrosis and icrrhoissi….often have metabolic syndrome…mildly elevated AST and ALT

HFE mutations that inc iron absorption….hepatomeaglay and cirrhosis

Question 6

Wilsons dz

AI hep

Answer 6

Defective cellular transport of copper leading to organ accumulation

1/2 will get liver dz before 30

Also common to have nuerpsy dz…suspect in pts with hemolytic anemia, lowcopper and low cerulosplasm

AI - CMI damage to hepatocyte…same as viral in dx…most have hypergammaglobulineia.

Tyope 1 - young women with pos ANA or smooth muscle AB

Type 2 - liver-kidney microsome AB and liver cytosol AB

Question 7

alpha 1 AT def

Acute liver failure

Answer 7

Common

Nonspecici

Defined by comps of hepatic encephalopathy and coagulopathy….aminotransferases over 1000….oftne thrombocytopenia as well

Question 8

Dx of hep B, hep C, hemochromatosis, NAFD, hep A, toxin/drugs

Answer 8

Mild elevation

Hep B tests
Hep C AB
Serum iron, TIBC
Ultrasound

Marked

IgM anti-hep A
Hep B
Heb C AB and viral load
acetominophen level

Question 9

Gallstones
Primary biliary cholngitis
Primary sclerosing cholangitis

Answer 9

If lodge n bile duct or without bact infection, look for inc alk phos and bilirubin….May have elevation in AST and ALT as welll…triad of fever, RUQ pain, and jaundice

Women 40-60 with insidous onset of sx….frequenyl other AI dz and get hypercholesterolemia and pos anti-mito AB

Young men 20-30 with IBD….asx with eventual jaundice and prutirs

Question 10

Dx of cholestatic conditions

Answer 10

If inc alk phos, get US to localize the location….if dilated, then extraheptic cholestasis

If extra - assume to have cholengitis and get ERCP to confirm

Sclerosing - string of beads areas of stensosi with mixed dilation

Question 11

Focal nodular hyperplasia

Answer 11

Hyperplastic regn responsr to hyperperfusion

ANomalous artery in center of a nodule or noram lappearing hepatocytes

Not a problem

Question 12

Hepatic adenoma

Answer 12

Most in premenopausal women 30-50 who take OCPs

More in the right lobe and have normal tests….rise in AFPs can mean malignant.l…tx with dec estrogen …

Question 13

Hepatic hemangioma

Answer 13

Most common and between 30-50 females….most related to vascular malformations

Question 14

Hepatic metastases

Answer 14

Most common

Most through portal venous system but can also be lung and breast

Question 15

Hepatoblastoma

Answer 15

From precurosor cells in the liver

Association with FAP, beckwith-wiedemann syndrome, trisomy 18 and trisomy 21

Large and asx abdominal mass….can get constitutuonal sx as it progress

Dx by CT or MRI….sually AFP elevation as welll

Resection

Question 16

HCC path and CM

Answer 16

Most in setting or chronic liver dz or chronic viral hep

Hep B associated - integrates into hepatocyte DNA and activates MAP and JAK/STAT baths that inhibt apoptosis

Chronic inflamm liver dz - inc hepatocyte turnover, dminish signals inhibiting, and ROS

Most are asx - comps when into the portal venous system

HYpoglycemia - secretes IGF
Erythrocytosis - secrete EPO

Question 17

Dx, mg of HCC

Answer 17

Annual ultrasound and AFP

CT or MRI can help

HCChas greater enhancement or arterial phase and lesser on venous

Large multinucelated giant cells with central necoriss

Surgery or ablation…maybe liver trnasplant…only chemo is TK inhibitor sorafenib