Exam 1: Liver Test And Hepatitis Flashcards
What is 5NP?
A liver enzyme that is elevated in diseases affecting the biliary tree. 5NP can help distinguish liver as the origin
When GGT elevated simultaneously with ALP, what does this indicate?
It confirms liver origin
What is the first step in evaluation of a patient with elevated LFTs but no symptoms?
Repeat the test (fasting)
When is GGT useful?
1) when ALP is elevated, it confirms liver specificity
2) When AST/ALT is >2 it further supports alcoholic liver disease (ALD)
What liver tests assess liver function?
Bilirubin, albumin, and PT/INR
What labs are going to be elevated with hepatocellular damage?
ALT and AST
What labs will be elevated with a cholestatic process?
Total bilirubin, ALP, and GGT
What does elevated ALP suggest?
Cholestasis
What is fractionated bilirubin and when is its useful?
Fraction of total bilirubin that is direct vs indirect.
Useful when standard liver tests are normal and total bilirubin is elevated (hemolysis and Gilbert syndrome)
What happens to UDP glucoronyl transferase in Gilbert syndrome?
Activity is reduced by 30% so unconjugated bilirubin is not being conjugated and there is decreased bilirubin secretion
What lab findings are consistent with liver disease?
Elevated direct bilirubin and elevated ALT and AST
What lab findings are consistent with hemolysis?
Elevated indirect bili, anemia, normal AST and ALT
What lab findings are consistent with Gilbert syndrome?
Elevated total bili, elevated indirect bili, normal ALT and AST, no anemia
Do normal liver tests mean that the liver is normal?
NO
Is there a relationship between severity of liver disease and transaminase levels?
NO
Where is GGT found?
Hepatocytes and biliary epithelial cells
What herbals/vitamins can cause drug induced liver injury (DILI)?
Ephedra, Kava, VItamin A, and Garcinia Cambogia
What are the medications that can cause DILI?
Acetaminophen, Statins, antifungals, antibiotics, Anti TB drugs, NSAIDs, tegretol
What are causes other than liver injury/damage that can cause elevated LFTs?
Muscle injury, cholelithiasis, masses, hemodynamics disorders, celiac, hypothyroid and adrenal insufficiency
What labs can be elevated in muscle disorders?
CPK and aldolase
What conditions are associated with mildly elevated AST and ALT?
Fatty liver, EtOH, chronic viral hepatitis, and medication effects
What conditions are associated with AST> ALT?
Alcoholic hepatitis, rhabdo, cardiac, and cirrhosis
What is a AST: ALT ratio of >2 suggestive of?
Alcoholic liver disease
What is AST/ALT ratio of less than 2 suggestive of?
Acute or chronic viral hepatitis, cholestatic disease, NASH, and cirrhosis
What is NAFLD?
Non-alcoholic fatty liver disease with no secondary cause for fat accumulation .
No inflammation and low risk of developing significant fibrosis
What is NASH?
Non alcoholic steatohepatitis, fatty liver with inflammation with hepatocyte injury and fibrosis.
-Higher risk of developing significant fibrosis, cirrhosis, liver failure, and liver cancer
What can NASH progress to?
Cirrhosis
What is the strongest predictor for NASH?
Metabolic syndrome
What are the risk factors for NAFLD?
Abdominal obesity, DM, HLD, metabolic syndrome, and polycyclic ovarian syndrome
How is NASH diagnosed?
Mildly elevated ALT and AST, fatty infiltration on imaging, negative work ups for other causes of NASH, and possibly liver biopsy
What will a liver biopsy show in a NASH patient?
Steatosis, inflammation and fibrosis
What is the management for NASH?
Diet and exercise, reduce EtOH, control DM and HLD, and transplant if progressed to cirrhosis
What is hereditary hemochromatosis?
Autosomal recessive, most commonly due to mutations in HFE gene.
-Genetic mutation that results in increased iron absorption and iron accumulation in liver, pancreas, heart, kidneys, etc
What can hereditary hemachromatitis do to the liver? What increases this risk?
May lead to fibrosis and cirrhosis.
Excessive EtOH intake and co-existing conditions increase risk
What labs findings are seen with hereditary hemochromatosis?
Elevated AST and ALT
What should you do when you have a patient with hereditary hemochromatosis with elevated transferrin saturation or elevated ferritin?
Refer to GI for HFE genotype analysis and further work up
What is the treatment of hereditary hemochromatosis?
- Cirrhosis prevention by avoiding vitamin C, iron supplements,EtOH, and uncooked seafood
- Therapeutic phlebotomy
- Hep A and B immunization
What is Primary biliary cholangitis?
Immunologic attack on the intrahepatic bile ducts that eventually leads to cirrhosis and liver failure.
What test is positive in primary biliary cholangitis?
Anti-mitochondrial antibodies (AMA)
What is autoimmune hepatitis?
Hepatocellular inflammation presumed T-Cell mediated immune attack of liver antigens
What is primary sclerosis cholangitis?
Inflammation and fibrosis of the intrahepatic and extraheptic ducts. Strong association with IBD
Is AMA positive or negative for primary sclerosis cholangitis?
Negative
What autoimmune liver diseases are predominantly in women?
Primary biliary cholangitis and autoimmune hepatitis
What labs test should you order in autoimmune hepatitis?
Antinuclear antibodies, anti smooth muscle antibodies, liver kidney microsomal antibody, and liver cytosol
What is alpha 1 antitrypsin deficiency?
Genetic disorder characterized by decreased level of normal alpha 1 antitrypsin, which protects against tissue injury
What is Wilson’s disease?
A rare hereditary disorder of copper metabolism caused by an autosomal recessive defect.
-Causes impaired biliary excretion and elimination of copper from the liver
How does Wilson’s disease cause liver damage?
Copper accumulates to toxic levels in the liver and copper is released into the blood stream, which accumulates in the brain, cornea, joints, kidney, heart, and pancreas
What are the clinical findings of Wilson’s disease?
Predominantly hepatic, neurologic, and psychiatric (tremor, involuntary movements, dysarthria, muscle spasticity, etc)
What is a Kayser-fleisher ring and what disease is it associated with?
fine pigmented granular deposits in the cornea.
Associated with Wilson’s disease
How is Wilson’s disease diagnosed?
Elevated AST and ALT, ALP low, serum cerulplasmin, high urinary copper, and possible liver biopsy and genetic testing
How is Hepatitis A spread?
Fecal oral route
What labs findings are associated with hepatitis A?
Significantly elevated AST/ALT, elevated ALP, elevated bilirubin
What test is diagnostic for hepatitis A?
Anti-HAV IgM
How is hepatitis B spread?
Sexual contact, parenteral, person to person, peri-natal transmission
Does Hepatitis A ever become chronic?
No
