Bloods

Question 1

What can raised alt indicate?

Answer 1

Specific for liver: acute liver disease. Level correlate with severity.

Question 2

Normal ast:alt? What does increased ratio indicate?

Answer 2

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If ≥ 1: chronic liver disease not caused by alcohol eg drugs (paracetamol, isoniazid), acute viral hepatitis

Question 3

What does a raised AST and alt indicate?

Answer 3

Hepato cellular damage

Question 4

Pathology if ast:alt > 2?

Answer 4

Chronic liver disease or failure by alcohol probably, cirrhosis

Question 5

Pathology if ast:alt > 5?

Answer 5

Rhabdomyolysis or extrahepatic eg mi

Question 6

What can raised alp indicate? (4)

Answer 6

• Bile duct obstruction (found in biliary epithelium)
• obstructive liver disease post-hepatic
• high bone turnover/loss eg fracture, hyperthyroid (found in bone)
• pregnancy (found in placenta)
• cholestatic liver injury: contraceptives, amoxicillin, clavulanic acid, chlorpromazine

If alp raised in isolation, cause is extrahepatic.

Question 7

What can lowered alp indicate? (3)

Answer 7

• Malnutrition (found in intestines)
• hypoadrenia (found in kidneys)
• protein deficiencies

Question 8

What can raised GGT indicate? (4)

Answer 8

• Bile duct obstruction! (Found in biliary epithelium)
• alcoholism! (Found in hepatocytes )
• excessive magnesium intake
. Hepatic cellular disease eg viral hepatitis, drug induced

Question 9

What is the next step if tb: CB <0,3?

Answer 9

Check alt and AST because hepatic cellular jaundice.

Question 10

What is the next step if tb: CB > 0,7?

Answer 10

Check GGT and alp first because obstructive/post hepatic jaundice.

Question 11

What does a much higher GGT than alp indicate?

Answer 11

Biliary or hepatic disease

Question 12

What does a much higher alp than GGT indicate?

Answer 12

Biliary disease only

Question 13

What does both a raised GGT and alp indicate?

Answer 13

Post hepatic or obstructive injury eg cholestasis, choledocholithiasis, primary biliary cirrhosis, cholangiocarcinoma, cholangitis, pancreatic mass
Or chronic diseases eg chronic active hepatitis

Question 14

What does a raised unconjugated bilirubin indicate? (7)

Answer 14

• Pre-hepatic jaundice
• haemolysis eg haemolytic anaemia
• ineffective haematopoeisis or abnormal red blood cells
• physiologic jaundice of the newborn
• Gilbert’s syndrome (decreased UGT, which conjugates bilirubin)
• crigler najjar syndrome (no ugt-fatal)
• fasting

Question 15

How does bilirubin get excreted? (2)

Answer 15

Stercobilinogen in stool
Urobilinogen in urine

Question 16

Differential diagnosis if conjugated bilirubin is 70% or more of the total bilirubin?

Answer 16

= post hepatic obstructive jaundice , eg:
• intraductal: gallstones, ascaris worms/flukes, choledocholithiasis
• extraductal: peri-ampullary malignancies (head of pancreas cancer, ampullary carcinoma or polyp )
• intramural: malignant stricture (cholangiocarcinoma) , benign stricture (chronic pancreatitis, primary sclerosing cholangitis

= genetics:dubin-johnson syndrome, rotor

Question 17

Differential diagnosis if conjugated bilirubin is 30 % or less of the total bilirubin?

Answer 17

= hepatic jaundice, eg:
• acute viral hepatitis b/c
• drug induced: paracetamol, aspirin, steroids, statins, halothane…
• Wilson’s disease
• Budd chiari syndrome
• pregnancy: intrahepatic cholestasis of pregnancy, pre-eclampsia, hyperemesis gravidorum…
• alcoholic liver disease
• hereditary haemochromatosis
• hepatocellular carcinoma

Question 18

Normal and jaundice values of total bilirubin?

Answer 18

Normal <17 micro mol /l
Jaundice > 35

Question 19

Name 3 causes raised albumin

Answer 19

• Dehydration
• chronic inflammation
• drugs: testosterone, growth hormone, insulin

Question 20

Name 4 causes low albumin

Answer 20

• Decreased synthesis by liver: chronic liver disease, malnutrition
• increased losses: nephrotic syndrome, protein-losing enteropathy
• internal redistribution: increased capillary permeability (haemodilution)
• tumour cachexia, liver inflammation and cirrhosis, pregnancy, congestive heart failure

Question 21

Name 2 symptoms low albumin

Answer 21

Pitting oedema, Ascites

Question 22

Name 2 causes raised INR

Answer 22

(bleeding risk)
• decreased synthesis clotting factors: chronic liver disease, vitamin k deficiency, anticoagulants
• increased consumption clotting factors: disseminated intravascular coagulation

Question 23

Which combination of blood results indicate liver cirrhosis? (3)

Answer 23

• High bilirubin
. Low albumin
• high INR
(High alt)