EXAM 3 Hepato-biliary and pancreas Flashcards
abdominal US
- gall stones
- biliary obstruction
- liver abscess
- liver mass, masses, or metastases
- pancreatic enlargement
test preferred for gall bladder
us
what will be seen in CT of gall bladder
only stones with significant calcium content
advantages of US of gall bladder
noninvasive, good for stones of all kinds, no radiation
LFTs that give info for cellular integrity
ALT- liver
AST- liver
gamma-glutamyl transpeptidase - liver and bile ducts
lfts that give info for cellular fx
protein, blood
bilirubin, indirect (unconjugated)
cholesterol
protime (INR)
LFT that give info for biliary obstruction
bilirubin, direct (conjugated) excretion obstruction
AP , cellular integrity
gamma-glutmyl transpeptidase- cellular activity
what happens if liver cells become ischemic or die (alcoholic hepatitis, viral hepatitis, drugs such as Tylenol, anticonvulsants, etc)
enzymes contained within the cell are freed and enter circulation and increase in concentration
what happens if liver cell fx is reduced (ie cirrhosis)
usual products of the liver (clotting factors, albumin, indirect or unconjugated bilirubin) are reduced and decreased concentrations may be detected
what happens if there is a biliary blockage
conjugated bilirubin is not eliminated
concentration builds up in blood and urine
if cells lining biliary ducts are stretched and irritated what can happen
leakage of alkaline phosphatase and gamma-glutamyl transpeptidase into blood
concentrations rise
common liver fx tests
cmp, albumin, AST, ALT, bilirubin, AP
used to detect asymptomatic liver disease and follow progression of disease after dx
AST can increase in what
liver disease
also heart attacks
ALT increases in what
increases up to x10 in cirrhosis, infections, or tumors
up to 100x in viral or toxic hepatitis
gamma glutamyl transferase used for what
monitors pt recovering from hepatitis and cirrhosis
lactate dehydrogenase is increased when
liver disease
and following heart attacks
alkaline phosphatase increases when
greatly increased in liver tumors and lesions (and metastasis)
moderately increased in disease like hepatitis
if pt has LFTs WNL but increase in AP consider what
maybe problem in liver, bones, kidneys, intestinal lining or placenta
ALT range
7 - 55 u/l
AST range
8 - 48 u/l
ALP range
45-115 u/l
albumin range
3.5 - 5.0 g/dl
total protein range
6.3 - 7.9 g/dl
bilirubin range
0.1 - 1.2 mg/dl
ggt aka gamma-glutamyl transferase range
9 - 48 u/l
ld range
122 - 222 u/l
what is bilirubin
breakdown of hemoglobin
unconjugated bilirubin
it hasn’t been through the liver yet – so a ton of heme being broken down (and it’s exceeding the pace of liver conjugation) or there’s something wrong with the conjugating capacity of the liver (like a congenital disorder where you’re missing an enzyme necessary for conjugation – for example, Gilbert syndrome)
conjugated bilirubin
means it’s been through the conjugation process in the liver – so there’s something preventing the secretion of bilirubin into the bile (likehepatitis or biliary obstruction), and the bilirubin is backing up into the blood.
what labs look like with acute liver damage (ie d/t infection, toxins, drugs, etc)
- bilirubin - normal or increased usually after ALT and AST already increased
- ALT and AST - usually greatly increased, ALT > AST
- ALP - normal or only moderately increased
- albumin wnl
- pt - usually wnl
chronic forms of various liver disorders
- bilirubin - normal or increased
- ALT and AST- moderately increased
- ALP - normal to slightly increased
- albumin wnl
- pt wnl
alcoholic hepatitis
- bilirubin - normal or increased
- AST usually x2 of ALT
- ALP - normal or moderately increased
- albumin wnl
- pt - wnl
cirrhosis
- bilirubin- may be increased but usually occurs later in disease
- AST usually higher than ALT but levels are usually lower than in alcoholic disease
- ALP - normal or increased
- albumin - usually decreased
- PT usually prolonged
bile duct obstruction, cholestasis
- bilirubin- normal or increased; increased in complete obstruction
- alt and ast - normal or moderately increased
- alp - increased, often 4x normal
- albumin - usually normal, but if disease is chronic levels may decrease
- pt - usually normal
cancer that has spread to liver - metastasized
- bilirubin - usually normal
- alt and ast - normal or slightly increased
- alp usually greatly increased
- albumin wnl
- pt wnl
cancer originating in liver- hepatocellular carcinoma, hcc
- bilirubin - may be increased, esp if disease has progressed
- AST higher than ALT but levels lower than see in alcoholic disease
- alp - normal or increased
- albumin usually decreased
- pt usually prolonged
autoimmune
- bilirubin- normal or increased
- alt and ast - moderately increased
- alp - normal or slightly increased
- albumin - normal or decreased
- pt wnl
Which of the following is a characteristic of acute alcoholic liver disease?
AST/ALT > 2
what is greatly increased in metastatic ca
alkaline phosphatase
true or false, Direct or conjugated bilirubin is expected to rise more that the unconjugated fraction in patients with biliary obstruction.
True
Conjugated bilirubin has been metabolized in the liver to make it water soluble so it can be excreted. When the bile ducts are obstructed, conjugated bilirubin backs up, and its concentration rises in the blood.
true or false, A patient with right upper quadrant pain exacerbated by a fatty meal can safely be said to not have gall bladder disease if the GGT, bilirubin and alkaline phosphatase are normal
false
When there is a high suspicion of gall bladder disease, patients should have an ultrasound examination of the gall blabber and biliary tract regardless of the results of the GGT, bilirubin and alkaline phosphatase
with biliary obstruction or inflammation you would expect to see elevation in what labs
bilirubin
alkaline phosphatase
GGT
what is test of cellular integrity of bile duct lining cells
alkaline phosphatase
what is test of liver cell integrity?
ast
what are amylase and lipase
enzymes released from pancreatic parenchymal cells when pancreas is inflamed or ischemic
when is blood amylase and lipase levels increased
with inflammation or ischemia
signs of acute pancreatitis
pt presents with acute onset of mid-abdominal or back pain (in lumbar area) “ band radiating to back”, fever, vomiting, and malaise
causes of pancreatitis
excess alcohol ingestion
gall stones in the pancreatic portion of the common bile duct
medications
highly elevated triglycerides
amylase timing
rises before lipase
rise within 12 hours of insult, decrease 48 - 72 hrs after insult
lipase timing
rise 24- 48 hrs and remain elevated 5 - 7 days
elevated longer than amylase
what is the test to rule in acute pancreatitis
lipase
24 hr urine amylase almost as good
other than pancreatitis, when else can lipase be elevated
renal impairment or intestinal infarction
clinical picture of hepatitis
abnormal LFTs, and s/s of acute viral infection- n/v/f, malaise, yellowing of skin
positive HAV ab IgM means what
acute infection
contagious
HAV Ab IgG means what
previous infection when HAV IgM is negative
immune
how does body respond to hep a with antibodies
body first responds with IgM antibody and secondarily with IgG antibody as a preventative against future infection
Hepatitis B antigen (HBsAg):
protein on surface of hep B virus
seen increased in serum during acute or chronic hep b infection
presence means pt is infectious
Hepatitis B surface antibody (anti-HBs):
generally indicates recovery and immunity from hep B infection
also seen in pts who have been successfully vaccinated against hep b
Total hepatitis B core antibody (anti-HBc):
Appears at the onset of symptoms in acute hepatitis B and persists for life.
The presence of anti-HBc indicates previous or ongoing infection with hepatitis B virus in an undefined time frame
IgM antibody to hepatitis B core antigen (IgM anti-HBc):
Positivity indicates recent infection with hepatitis B virus (<6 mos). Its presence indicates acute infection`
Anti-HCV (Antibody Hepatitis C Virus)
+ result does not always means pt has recovered from infection & developed immunity
may indicate current infection, 85% become carriers
if anti-HCV + order what to confirm dx
HCV RNA
HCV Viral Load
HCV Genotype –done after HCV dx confirmed
Refer to GI for liver biopsy/treatment if +
Marked increase risk for liver cancer or failure- will need to be followed at least yearly
often asymptomatic
