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chemical pathology > Chemical Pathology 18 - LFT cases > Flashcards

Chemical Pathology 18 - LFT cases Flashcards

1
Q

What 2 LFT results are very suggestive of alcoholic liver disease?

A

AST: ALT > 2.0
High GGT

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2
Q

When is ALP most markedly elevated?

A

Bile duct damage/ obstructive jaundice

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3
Q

What is the half life of albumin?

A

20 days

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4
Q

Systematically recall some reasons why albumin may be low

A
  1. Low production (chronic liver disease/ malnutrition)
  2. Loss (gut/ kidney (nephrotic))
  3. Sepsis, “3rd sponge” - due to endothelial leaking
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5
Q

What is the best measure of acute liver function?

A

Prothrombin time

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6
Q

Recall 4 scenarios in which AFP is raised

A
  1. Pregnancy (physiolgically)
  2. Hepatocellular carcinoma
  3. Testicular cancer
  4. Hepatic damage/ regeneration
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7
Q

What are the 2 possible causes of jaundice when LFTs are normal?

A

Gilbert’s
Haemolysis

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8
Q

In a jaundiced patient with a raised ALP, what should your diagnostic approach be?

A

Do a USS
If dilated ducts: gallstones/ cancer
If undilated ducts: drugs/ PSC/PBC/ pregnancy

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9
Q

What in the LFTs would indicate that jaundice had a hepatocellular origin?

A

Raised ALT/AST as opposed to ALP

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10
Q

How can you identify obstructive jaundice clinically without measuring bilirubin?

A

Pale stool and dark urine

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11
Q

What is the ELF score, and how is it calculated?

A

Enhanced liver fibrosis score

ELFs have a HAT

3 markers associated with fibrosis (HAT):

  • Hyaluronic acid
  • Amino-terminal propeptide of type III procollagen
  • Tissue inhibitor metalloproteinases
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12
Q

Which common drug is often implicated in cholestasis?

A

Augmentin (co-amoxiclav)

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13
Q

Which type of hepatitis is most common cause of acute viral illness in returning travellers?

A

Hepatitis A (water-borne)

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14
Q

What USS finding is very suggestive of liver cirrhosis?

A

Coarse liver

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15
Q

Which type of hepatitis is most likely to be transmitted by IV drug use?

A

Hep C

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16
Q

Where are the enzymes ALT and AST found?

A

They are intracellular ezymes within hepatocytes- found in the cytoplasm

so if they leak out this is indicatvie of liver damage

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17
Q

Where else is AST and ALT present?

A
  • Muscle
  • Kidney
  • Brain
  • Pancreas
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18
Q

Which conditions cause AST to rise in preference to ALT?

A

Alcoholic liver disease

AST>ALT: 2:1

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19
Q

Which other drug causes high AST levels?

A

Cocaine

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20
Q

Which liver enzyme is raised after an MI?

A

AST

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21
Q
A
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22
Q

Where is GGt found?

A

hepatocytes AND small bile duct epithelium

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23
Q

What are the causes of raised GGT?

A

Chronic alcohol use (abuse)

Drug injury

Bile duct disease (e.g. gallstones)

Hepatic metastases

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24
Q

Where is GGT found (which organs other than the liver?)

A

Kidney

Pancreas

Spleen

Heart

Brain

Seminal vesicles

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25
Q

Where is ALP found?

A

liver:

Liver isoenzyme located in the sinusoidal and canalicular membranes (bile ducts)

Other organs:

Bone

Small intestine

Kidney

WBCs

Placenta

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26
Q

If ALP is raised how do you confirm that it is a hepatic source?

A

Measure GGT as well

If GGt is raised as well then it is a hepatic source

27
Q

What causes raised ALP: hepatobiliary and other

A

hepatobiliary:

1) Obstructive jaundice
2) Bile duct damage (e.g. PSC, PBC)

other:

1) pregnancy- especially third trimester
2) bone disease- increased bone turnover due to increased activity of oestoblasts

  • Paget’s
  • renal osteodystrophy
  • fracture
  • metastatic disease

**NOT in multiple myleoma because you only get activation of osteoclasts not osteoblasts**

3) Vitamin D deficiency–>secondary hyperparathyoridism
4) Drugs

  • phenytoin
  • erythromycin
  • carbamezepine
  • verapamil

5) Congestive cardiac failure
6) Cancer

  • breast
  • colon cancer
  • Hodgkin’s lymphoma
28
Q

What are the markers of liver synthetic function?

A

Clotting

Albumin

29
Q

Causes of low albumin

A

1) Hepatobiliary
* CHRONIC liver disease (not acute as albumin has a long half life)
2) Other

  • Nephrotic syndrome
  • Protein losing enteropathy
  • third spacing eg in sepsis (leaks out from capillaries into interstitial space)
30
Q

Best marker of acute liver dysFUNCTION

A

CLOTTING CASCADE- PROTHROMBIN TIME

as the proteins in the clotting cascade have a short half life (as opposed to albumin which has a long half life)

31
Q
A
32
Q

What is bilirubin a marker of?

A

Bit of both - liver dysfunction and liver damage

33
Q

Best marker of chronic liver dysfunction

A

Albumin (will be low)

34
Q

Causes of raised AFP?

A
  • Hepatocellular carcinoma
  • Testicular cancer
  • Pregnancy
  • Also raised in hepatic damage/ regeneration
35
Q

Conjugated vs unconjugated hyperbilirubinaemia

A
36
Q

Summarise the approach to jaundice

A
37
Q

If jaundice/ high bilirubin but the LFTs are NORMAL (2):

A

1) Haemolysis
2) Gilbert’s

38
Q

If jaundice/ high bilirubin but there is a predominantly RAISED ALP:

A

1) Dilated ducts (i.e. obstruction)
- gallstones
- cancer of the head of the pancreas
2) undilated ducts
- co-amoxiclav
- PBC/PSC
- pregnancy

**in all of these causes (cholestasis) you would see: rise in GGT and ALP are GREATER than rise in AST/ALT**

39
Q

If jaundice/ high bilirubin but mainly AST/ ALT are RAISED:

A

Hepatocellular liver damage

a) Acute

b Chronic

40
Q

In clnical practice what is the approach to jaundice?

A
41
Q

causes of transaminases > 1000

A

Viruses

Toxins e.g. paracetamol

Ischaemia e.g. cardiac arres

42
Q

When would you do a urine dipstick in the context of abnormal LFTs?

What would you see?

A

If you’ve got DARK URINE + PALE STOOLS - obstructive jaundice

Urine dip:

1) raised urinary bilirubin (conjugated- soluble) - this is visible to the naked eye
2) DECREASED urinary urobilinogen (this is produced by bacteria in the gut; if you have an obstruction, bile cannot get into the gut so levels will be low)

43
Q

Causes of increased urinary urobilinogen

A

1) haemolysis
2) hepatitis
3) sepsis

44
Q

What does a more extensive liver panel consist of?

A
45
Q

Which other imaging (sophisticated) can be used for PSC?

A

MRCP

46
Q

Which sophisticated tets can be used for haemchromoatosis?

A

MRI iron load

47
Q

NAFLD symptoms

A

right upper quadrant pain

or may be asymptomatic

48
Q

LFTs in NAFLD

A

raised AST and ALT levels (AST:ALT ratio <1)

increased GGT

Bilirubin and albumin levels are normal

49
Q

LFTs in paracetamol overdose

A
  1. transamanitis in the 1000s (much larger rise in this compared to GGT and ALP)

clinical picture: acute liver failure

  • Reduced synthetic and metabolic functioning
  • Reduced blood sugar
  • Metabolic acidosis
  • Increased tendency to bleed
  • hepatic encephalopathy
50
Q

Causes of isolated rise in GGT

A
  1. acute alcohol abuse
    - big rise in GGT (maybe a minor rise in AST,ALT indicating minor liver damage)
    - would also see macrocyctosis
  2. enzyme inducing drugs

phenotyoin

carbamazapine

phenobarbitone

51
Q

Isolated rise in uBR?

A

Gilbert’s

  • high total BR
  • normal conjugated BR
52
Q

Isolated rise in conjugated BR?

A
  • DUBIN JOHNSON SYNDROME
    • autosomal recessive disorder
    • LFTs:raised conjugated BR level
    • due to reduced secretion of conjugated bilirubin into the bile
    • AST and ALT levels - normal
53
Q

What do raised serum bile acids indicate?

A

1) cholestasis of pregnancy
2) PBC/PSC

54
Q

What is the Indocyanine green/ Bromsulphalein dye test?

A

Measure excretory capacity of the liver

Measure hepatic blood flow

55
Q

What is the Aminopyrine/ Galactose (carbon 14) test?

A

Measures residual functioning of liver cell mass

looks at intermediary metabolism

56
Q

Gold standard diagsnosi of fibrosis and alternatives

A

Gold standard: liver biopsy

Alternatives: fibroscan,

57
Q

In which types of jaundice is spelnomegaly preset?

A

prehhepatic and hepatic

*not post hepatic*

58
Q

Explanation for dark urine and pale stools in obstructive jaudnice

A

Dark urine seen due to increase urobilinogen/conjugated BR (lots of them
absorbed by blood), pale stool = low levels of stercobilinogen + dark urine

59
Q
A
60
Q

Causes of low urea

A

Severe liver disease, (synthesised in liver), malnutrition, pregnancy

61
Q

Causes of raised urea

A

1) Upper GI bleed (or large protein meal)
2) Dehydration/AKI (urea excreted renally)

62
Q

Hepatomegaly with smooth margin

A

Viral hepatitis, biliary tract obstruction, hepatic
congestion 2° to (HF; Budd Chiari)

63
Q

Hepatomegaly with a craggy border

A

Hepatic metastatic disease, polycystic disease,
cirrhosis (will shrink)

64
Q

In the absence of alcohol, an AST: ALT ratio > 0.8 suggests?

A

advanced liver fibrosis/cirrhosis

chemical pathology (22 decks)

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