Hepatic Flashcards
Four causes of increased mean corpuscular volume (RBC size)
- B12 deficiency (Pernicious anemia)
- Chronic liver disease
- Alcoholism
- Folic acid deficiency
How do the following lab values change in anemia of pregnancy?
1. Serum iron
2. Transferrin
3. TIBC
4. TS
- Low
- High
- High
- Low in late pregnancy
AST/ALT ratio in end stage liver disease
Normal!
Three causes of decreased mean corpuscular volume (RBC size)
- Iron deficiency
- Thalassemia
- Anemia of chronic illness
How do the following lab values change in anemia of chronic illness?
1. Serum iron
2. TIBC
3. Transferrin saturation
- Low
- Low
- Normal
CRP is a non-specific acute-phase reactant that is elevated 2 hours after a/an [blank] process
Inflammatory process
Gilbert’s syndrome causes this change in this type of bilirubin
Increase in indirect bilirubin
Which two populations have variations in their normal AST values, and how are they different?
- Blacks = 15% higher AST
- Exercisers = higher AST (number unspecified)
Two main factors (not diseases) that change ALP levels and how they affect levels
- Pregnancy (2-3x in 3rd trimester)
- Oral contraceptives (20% lower)
Which, MRCP or ERCP, is more invasive?
ERCP
(MRCP is non-invasive)
Most common cause of an increased blood albumin level
- Dehydration is most common
(also poor blood draw technique or specimen evaporation/poor storage)
Is ALP elevation seen more in intrahepatic or extrahepatic obstructions?
Extrahepatic obstructions
Any individual with symptoms suggestive of iron deficiency anemia should have these two labs drawn
- Iron study
- CBC
Two causes of microcytic, hypochromic anemias
- Iron deficiency
- Thalassemia
Two primary reasons to order liver function tests (LFTs)
- To confirm a clinical suspicion of potential liver injury or disease
- To distinguish between hepatocellular injury and cholestasis
True or false. CT is not very helpful in imaging the biliary tree
True
Three main lab changes in alcoholic hepatitis (chronic alcoholism)
- Hypoalbuminemia
- ALP mildly elevated
- If severe, elevated PT/PTT/INR
Which, direct or indirect bilirubin, is conjugated?
- Direct = conjugated (water soluble)
- Indirect = unconjugated
True or false. Normal AST/ALT excludes liver disease
False
(liver cirrhosis and hep C can have normal LFTs)
Subacute liver disease time frame
Between 8 weeks and six months duration
Three things that can elevate ESR (erythrocyte sedimentation rate)
- Menstruation
- Oral contraceptives
- Pregnancy
Which, the PT or PTT test, is used to assess the intrinsic system and common pathway of clot formation?
PTT
What is measured in a CMP that relates to the liver?
Proteins
- Albumin
- Total protein
LFTs
- ALP
- ALT
- AST
- Bilirubin
Which, AST or ALT, is more specific for liver damage?
ALT
Do hepatocellular diseases typically shorten or prolong PTT?
Prolong PTT
Coagulation factors are made in the liver, so hepatocellular disease means less factors, and longer PTT
What test is used to differentiate between vitamin K deficiency and liver disease in patients with elevated PT/INR?
Administer vitamin K and monitor PT response
AST/ALT ratio that suggest alcoholic liver disease
> 2:1
Main causes of direct hyperbilirubinemia
- Hepatocellular disease
- Extrahepatic and cholestatic disease
(intra and extra hepatic diseases)
In the case of mildly elevated AST and ALT further evaluation is needed. What are three follow-up tests you could perform to narrow your diagnosis?
- Hepatitis assessment (A, B, C)
- Hemochromatosis (iron tests)
- Autoimmune hepatitis (ANA test)
Expected ESR and CRP levels in a patient with bone/joint infections
- High ESR
- Low CRP
Does a factor V Leiden mutation increase or decrease blood clotting?
Increases blood clotting
LDH is nonspecifically elevated in many conditions. However it is sometimes useful in diagnosing these three conditions
- Acute viral hepatitis
- Ischemic hepatitis
- Malignancy in liver
Causes of macrocytic anemias
Megaloblastic anemias
- B12 deficiency
- Folate deficiency
What is the first antibody made by the immune system to fight new infections?
IgM
(presence = acute infection)
Main contraindication for percutaneous liver biopsy
Any kind of bleeding issue
(also gross ascites, prolonged PT, thrombocytopenia, and extrahepatic cholestasis)
Normal range of total bilirubin
0 to 1.0 mg/dL
When receiving lab results for an ANA test your result simply says “positive”. Did you order a direct or indirect test?
“Positive” = direct ANA test, done by ELISA
What information can a HIDA scan of the liver reveal?
Function
- tracks the flow of bile from liver to small intestine
- integrity of the hepatobiliary tree
(if gallbladder fails to fill = abnormal)
How does AST typically change with the presence of gallstones?
AST 10x normal with gallstones
Causes (4) of indirect hyperbilirubinemia
- RBC hemolysis
- Hepatitis
- Drug reactions
- Hereditary disorders (G6PD deficiency and Gilbert syndrome)
AST/ALT levels in liver cirrhosis and hepatitis C
Normal
(normal AST/ALT doe not exclude liver disease)
Four main roles of the liver
- Purification
- Synthesis
- Transformation
- Storage
Which, INR or PT, is preferred for measuring clotting time?
INR - because standardized
Which blood coagulation test measures the final step of coagulation, the conversion of fibrinogen to fibrin?
Thrombin time (TT)
In a patient with hepatic symptoms but uneventful or non-diagnostic labs or LFTs that are still elevated even after alcohol cessation, what is the next diagnostic step?
Percutaneous liver biopsy
Causes of normocytic, normochromic anemias
- Blood loss
- Hemolysis
- Chronic disease
How will these values change in viral hepatitis (need to know):
- Transaminases
- Bilirubin
- Alkaline phosphate
- PT/PTT
- RBC
- WBC
- Lymphocytes
- Platelets
- Transaminases = UP
- Bilirubin = UP
- Alkaline phosphate = UP
- PT/PTT = normal
- RBC = mild anemia
- WBC = DOWN
- Lymphocytes = atypical
- Platelets = DOWN
Rheumatoid factor is normally negative. Name two conditions where the result would be positive
- Rheumatoid arthritis
- Sjogren’s syndrome
Expected ESR and CRP levels in a patient with a UTI or GI infection
- High CRP
- Low ESR
Acute liver disease time frame
Disease of less than 8 weeks duration
These three conditions cause prolonged aPTT. Which deficiencies are they associated with?
1. Von Willebrand disease
2. Hemophilia A
3. Hemophilia B
- Von Willebrand factor (which carries factor 8) is deficient
- Factor 8 is deficient
- Factor 9 is deficient
What is the gold standard for visualizing the biliary tract?
ERCP
(endoscopic cholangiopanreatography)
Following the completion of a hepatitis B vaccination series, use these antibodies alone to verify immunity
Anti-HBs
(surface antigen, not core antigen = immunity without exposure)
In iron deficiency anemia, how will these levels change?
1. Serum iron
2. Ferritin
3. TIBC
4. Transferrin
5. Transferrin saturation
- Low
- Low
- High
- High
- Low
Expected levels in fatty liver for:
- ALP
- AST/ALT
- ALP: normal or mildly elevated
- AST/ALT: normal or mildly elevated
These antibodies are used in the diagnosis of chronic HBV infection
- HBcAb-IgG (chronic)
- HBsAg (infected)
Prior exposure to hepatitis A is indicated by presence of this antibody
IgG anti-HAV
(will be present for life)
Jaundice will typically appear when bilirubin reaches this level
> 3 mg/dL
Which clotting factors are associated with the common pathway?
1, 2, 5, 10
Which clotting factors are associated with the extrinsic system?
7 only
In adults who have had appendicitis symptoms for longer than 24 hours, a normal level of [blank] has a 97-100% negative predictive value for appendicitis
CRP
(if CRP is normal after more than a day of symptoms they almost certainly don’t have appendicitis)
In chronic liver disease, is ALT or AST typically higher?
ALT > AST in chronic liver disease
More than 95% of our ALP comes from these two organs
- Liver
- Bone
(1:1 ratio)
In patients with normal liver labs other than increase of GGT (gamma glutamyl transpeptidase/transferase) what is the next diagnostic step?
No further workup if isolated GGT elevation
Gold standard diagnostic test to diagnose liver conditions
Percutaneous liver biopsy
What is the first imaging modality usually used to evaluate for intra and extrahepatic biliary dilatation?
Ultrasound
True or false. In acute viral hepatitis, transaminases are first to be elevated and often last to return to normal
True
Acute hepatitis A infection is diagnosed by the presence of this antibody
IgM anti-HAV
(appears within four weeks of exposure, disappears after three months)
If you suspect an autoimmune disease in your patient, start by ordering these three tests
- ANA
- ESR
- CRP
Definition of thrombophilia
- A hereditary or acquired disorder
- Marked by an abnormal increase in blood clotting
- Higher than normal risk of thrombosis
Which hepatitis is not an RNA virus?
Hep B is the only one which is a DNA virus
Which hepatitis strains are included in a hepatitis panel?
A, B, and C
These antibodies/antigens are used in the diagnosis of acute HBV infection
- HBcAb-IgM (acute)
- HBsAg (infected)
Five extrahepatic factors that affect AST and ALT
- Day to day variation (10-30%)
- Increase in BMI
- Being black (15% higher AST)
- Exercise (AST up, ALT down)
- Muscle injury/rhabdomyolysis (AST up more than ALT)
Hepatitis B patients with this antibody have a higher viral load have higher rates of transmission
HBeAg
Viral hepatitis typically has this AST/ALT ratio
AST/ALT ratio less or equal to one in viral hepatitis
Albumin binds and transports high protein drugs in the blood, what is an example of this kind of drug?
- Warfarin
Chronic liver disease/hepatitis time frame
Abnormal LFTs for more than 6 months
In acute alcoholic hepatitis is ALT or AST typically higher?
AST > ALT in acute alcoholic hepatitis
When a patient’s rheumatoid factor (RF) is low, the diagnosis of rheumatoid arthritis (RA) can still be made if [blank] is elevated
Anti-CCP elevated = rheumatoid arthritis
Normal AST/ALT ratio
<1
Normal INR range
0.8 to 1.1
What is the most abundant antibody found in all body fluids that protects against bacterial and viral infections?
IgG
If AST/ALT levels are more than 300x normal, consider these two possible causes
- Toxic hepatitis
- Ischemic hepatitis
AST/ALT levels are rarely >300 in cases of non-hepatic disease, other than in this one exception
Rhabdomyolysis = AST/ALT >300
ANCA (antineutrophil cytoplasmic antibody) is normally negative. Name three conditions where the result would be positive
- Wegener granulomatosis
- Ulcerative colitis
- Crohn’s disease
This antibody is associated with lupus and other autoimmune rheumatic diseases
ANA
Clinical definition of liver failure
When liver is unable to perform biosynthetic function
How would cholestasis affect ALP levels
Moderate elevation
Which, the PT or PTT test, is used to assess the extrinsic system and common pathway of clot formation?
PT
Which, PTT or aPTT is considered to be more sensitive?
aPTT
It’s the same as PTT, but with an activator added which speeds clotting time, leading to narrower reference range and more sensitivity
Three indications for ERCP
- Stone disease (jaundice, biliary pain)
- Ampullary/papillary abnormalities (sphincter of Oddi)
- Biliary and pancreatic ductal abnormalities (gallstones, acute/chronic pancreatitis)
High levels of ammonia in the blood support the diagnosis of this liver related condition
Hepatic encephalopathy
Differences between ERCP and MRCP
ERCP
- invasive
- endoscopy + radiographic contrast + fluoroscopy
- diagnostic only
MRCP
- non-invasive
- like an MRI but for the intra and extrahepatic biliary tree and pancreatic ductal system
- therapeutic as well as diagnostic
Which clotting factors are associated with the intrinsic system?
8, 9, 11, 12
AST (aspartate aminotransferase) is a lab ordered to measure function in these nine body systems (in order of frequency) must know
In order of frequency
- Liver, heart
- Skeletal muscles
- Pancreas
- Kidneys, brain, lungs, WBC, RBC
What are the most widely ordered lab tests that reflect hepatocellular damage?
Aminotransferases/Transaminases
(AST + ALT)
True or false. Albumin is synthesized exclusively by the liver
True
What is the most common (general) cause of liver inflammation?
Liver inflammation = hepatitis
Most common cause = viral infection
(also toxic/drugs, and autoimmune)
What is the most sensitive test for iron deficiency anemia?
Ferritin (protein for iron storage)
Low ferritin = iron deficiency anemia
Expected levels in cirrhosis for:
- AST/ALT
- Albumin
- PT
- AST/ALT: normal (especially in end stage disease)
- Hypoalbuminemia
- PT prolonged
The liver detoxifies ammonia into [blank]
Urea
Most important things (7) stored in the liver
Glycogen
Vitamins
- K, A, D, E, B12
Iron
- Ferritin
True or false. Hemoglobin amount is reduced in all anemias
True
In iron deficiency anemia, how will these levels change?
1. Ferritin
2. Serum iron
3. RDW (RBC distribution width)
4. TIBC
5. Hemoglobin and hematocrit
- Low
- Low
- High
- High
- Low
Clinical definition of cirrhosis
Late stage of scarring/fibrosis of the liver
Five intrahepatic factors causing marked elevations of AST/ALT must know
- Drugs/toxins (>3000)
- Ischemic hepatitis (>3000)
- Acute viral hepatitis (<3000)
- Acute biliary obstruction (<3000)
- Autoimmune hepatitis (<2000)
What is our most important protein, that maintains colloid osmotic pressure?
Albumin
Which antibody is found in high concentrations in mucous membranes, particularly lining the respiratory and GI tracts, as well as saliva and tears?
IgA
After ordering an ANA, ESR, and CRP in a patient you suspect has an autoimmune disease your results are inconclusive. What three tests can be considered in addition to narrow your diagnosis?
- Rheumatoid factor (RF)
- Anti-CCP
- ANCA
True or false. By itself, low serum iron, is not diagnostic of any condition
True
It must be evaluated with transferrin saturation and ferritin
ALT (alanine aminotransferase) is found predominantly in these two organs
- Liver
- Kidneys
Three things indicated by total protein and albumin lab results
- Nutrition status
- Chronic illness
- Liver disease
Which type of coagulation test goes with each of the following descriptions?
1. Evaluates ability to clot
2. Ensures that results are the same from one lab to another
3. Determines if blood-thinning therapy is working
- PT - prothrombin time
- INR - international normalized ratio
- PTT - partial thromboplastin time
Do patients need to fast for a complete metabolic panel? If so, how long?
Yes, order fasting for 10-12 hours
What is the difference between TIBC (total iron binding capacity) and ferritin tests?
TIBC measures all proteins for binding mobile iron in the blood (not ferritin)
Ferritin measures amount of iron stored in cells
