Hepatobiliary Flashcards
1
Q
Enzyme tests for liver INFLAMMATION
A
- Tests for liver INFLAMMATION b/c elevation of these enzymes can be found in other tissues unrelated to liver
- ALT
- AST
- ALP
- GGT
2
Q
Test for liver FUNCTION
A
- Bilirubin
- Albumin
- Ammonia
- Prothrombin
- AFP - alpha fetoprotein (AFP)
3
Q
Indications for liver function tests
A
- Symptoms of liver disease
- Jaundice
- RUQ pain/swelling - protein and fluid imbalance
- Itchy skin - pruritus (toxin buildup)
- Dark (coca colored) urine - excreting bilirubin
- Pale stool - excreting bilirubin
- N/V
- Easy bruising - problems w/clotting
- Loss of appetite
- Chronic fatigue
- If patient has risk/concern for VIRAL hepatitis exposure or NAFLD/NASH
- Medication monitoring: APA, lamisil, fibrates, statins, niacin
- Disease monitoring
4
Q
Which metabolic panel has LFTs included?
A
CMP - GGT, bilirubin and albumin left out
NOT BMP
5
Q
Most specific liver enzyme test for hepatic injury
A
ALT
6
Q
Causes for elevation of ALT
A
- Found in hepatocytes; also comes from kidney, less from skeletal and cardiac mm
- Hep A, B, C
- Acute drug injury
- EtOH and non-EtOH fatty liver
- Genetic + autoimmune liver problems
- Burns, skeletal trauma
- LOOK AT HOW MUCH HIGHER ABOVE NORMAL RANGE (2x, 3x, 4x, etc)
- Higher in infants than adults + children
7
Q
AST present in which tissues?
A
- Liver
- Cardiac mm
- Skeletal mm
- Kidney
- Brain
8
Q
Causes for elevation in AST
A
- Liver problems: hepatitis, cirrhosis, drug induced liver injury, metastasis, mononucleosis w/hepatitis
- Skeletal mm problems: Trauma, non-cardiac surgery, severe burns, muscular dystrophy, heat stroke
- Higher in infants + elderly vs adults
- MM wasting cause in elderly
9
Q
normal ALT + ⇡AST suggestive of?
A
Cardiac or mm disease
As opposed to liver issue
10
Q
Causes of ALP elevation
A
- Problem in hepatobiliary system
- Biliary disease: think biliary tract disease (stones) or infiltrative disease
- Pregnancy d/t placental synthesis
- Bone diseases
- Tumors, Paget’s, kids growing, hyperparathyroidism
11
Q
⇡ALTs AND ⇡ ALP suggestive of?
A
Elevation of these suggest liver related issue
12
Q
What to order next if elevation in ALP related to liver-biliary system?
A
GGT
BUT, no need to order if ALP and AST elevated
13
Q
Causes of GGT elevation
A
- Not specific
- Liver problems: hepatitis, cirrhosis, liver tumors, hepatotoxic drugs
- MI
- EtOH ingestion
- Pancreatitis or pancreatic cancer
- EBV aka infectious mono
- NOT PRESENT IN BONE
14
Q
↑ ALP, ↑ GGT, (-) hCG = _______
A
BILIARY ISSUE
Get a pregnancy test as ALP is elevated in pregnancy
15
Q
↑ ALP, ↓ GGT = ________
A
BONE ISSUE
Remember: no GGT in bone!
16
Q
↑ ALT, ↑ AST, normal ALP = ___________
A
Hepatocellular issue (LIVER)
17
Q
↑ ALP, normal AST/ALT = __________
A
Biliary but related to bone and other sources w/GGT
18
Q
Degree of elevation categories
A
- Borderline: < 2x ULN
- Mild: 2-5x ULN
- Start lab workup at this stage
- Moderate: 5-15x ULN
- Severe: > 15x ULN
- Massive AST or ALT > 10,000 IU/L
19
Q
Causes of Mild-moderately elevated ALT/AST
A
- Common
- NAFLD + EtOH (get hx)
- Less common
- Meds: OTC, vitamins, etc
- Viral Hepatitis, B + C, A (acute s/s)
- Hemochromatosis = elevated iron levels
- Rare
- Alpha I antitrypsin deficiency
- Autoimmune disease (copper?)
- Wilson disease (copper?)
20
Q
AST : ALT > 2 indicative of?
Which lab elevation makes it even more suggestive of this issue?
A
ALCOHOLIC LIVER DISEASE (still get hx)
GGT > 2x ULN
21
Q
Common causes of ALT/AST elevation in ASYMPTOMATIC patients
A
- Autoimmune
- (B) Hep
- (C) Hep
- Drugs, toxins
- EtOH
- Fatty liver
- Growths (TUMOR)
- Hemodynamic disorder (CHF)
- Iron (hemochromatosis), Copper (Wilson’s), alpha-1 antitrypsin deficiency
- Muscle injury
22
Q
Work-up of mildly elevated transaminases
A
First confirm by either repeating labs or performing clarifying test (GGT)
Only go through algorithm if acutely ill. Repeat in 3-4 weeks to see trend
Fatty liver disease RFs: high cholesterol, abd obesity, HTN, etc
Viral Hep RFs: IV drug use, high risk sexual activity (no protection), etc
Check iron panel - ferritin level - hemochromatosis
Albumin, Hep B, C; Abd U/S
23
Q
Why is having excess fat in liver a problem?
A
Makes it more difficult for liver to function
Fat → inflammation
24
Q
NAFLD
A
- Non-alcoholic fatty liver disease
- Has little to no inflammation
- Signs + Symptoms
- Metabolic syndrome (HTN, lipids, high TG level + low HDL, elevated BG) → need to be well-controlled to manage liver inflammation
- NAFLD fibrosis score = HIGH → GI referral → biopsy
- Inflammation → scarring → fibrosis
- Can progress to fibrosis and cirrhosis
25
NASH
* Non-alcoholic steatohepatitis
* **Inflammation present**
* See LFTs elevation → see CHRONIC damage
26
Liver disease progression
Hepatitis → Fibrosis → Cirrhosis → Cacner
Inflammation → scarring → severe scarring leaving irreversible damage → cancer
27
Fibrosis
Cirrhosis
ESLD
Liver failure
_Fibrosis:_ Inflammation *starts* to scar. Scar tissue replaces the normal, healthy tissue. It is difficult for blood to flow through a scared, stiff liver. Healthy liver has to compensate for the inflamed, scared liver.
_Cirrhosis_ is scared liver. Scared tissue replacing healthy tissue, can’t function well, eventually will not function (fail).
* Complications of cirrhosis: bleeding, edema, jaundice, itchy, diabetes, sensitivity to medications (ie liver not processing), toxin build up in brain, varices
* Chronic liver failure, cause death if no transplant to replace
* Not all end w/end stage liver disease, but put pt at risk more for cancer and disease
_End stage liver disease_: DECOMPENSATION, ex: hepatic encephalopathy, variceal bleed, ascites, kidney failure, lung transplant
_Cancer:_ transplant.
_Liver failure_: loss of function, confusion, disorientation, coma
28
Bilirubin transport (picture)
* Bilirubin byproduct of RBCs breakdown
* SPLEEN → breakdown of heme → unconjugated bilirubin needs attachment to albumin → LIVER → unconjugated biliubin \> conjugated bilirubin (via GBT) → INTESTINES → urobilinogen \> stercobilin
* Stercobilin gives stool brown color
* Pool pale = bilirubin not able to get into intestines!
* Unconjugated NOT excreted in urine, only conjugated bilirubin
29
Conjugated bilirubin in liver suggests a problem in…
Something wrong POST-HEPATIC
30
High levels of unconjugated bilirubin suggests a problem in…
INTRAHEPATIC
31
Direct bilirubin
Looks for **water soluble (conjugated) bilirubin**
32
Indirect bilirubin
Total bilirubin - direct bilirubin
33
Total bilirubin =
What does this tell you?
Conjugated + unconjugated
If it's hyperbilirubinemia
34
Prehepatic: dysfunction of and condition
* Unconjugated bilirubinemia issue
* Typically second to hemolysis
* Something is going wrong in breakdown of RBCs
* **Hemolytic anemia**
35
Intrahepatic conditions
* Unconjugated bilirubinemia
* Disorders of **enzyme metabolism** impending conjugation (**Gilbert syndrome**)
* Conjugated bilirubinemia
* **Intrahepatic choleestasis** or hepatocellular damage from **inflammation**
* **Flow of bile impaired from liver cells** where it is produced to small intestine
36
Posthepatic condition
* Conjugated bilirubinemia
* **Blockage in biliary system keeps bilirubin from being transported** (stones, tumor)
* Will often see **pale stools** and **dark urine** → d/t inability to excrete through biliary, goes into urine instead
37
Indications for Hepatic panel
* Acute jaundice
* Elevated bilirubin in asymptomatic patient
* Direct/Indirect bilirubin included: ALT, albumin, ALP, AST, +/- GGT
38
Urobilinogen indication for decreased levels
* Biliary disease - POSTHEPATIC
* Prevention of moving from biliary system into bowels
* Obstruction of conjugated bilirubin to bowel → less urobilinogen → PALE STOOLS
39
Urobilinogen indication for increased levels
* Increased in hemolytic process, hepatic disease
* Some goes back to liver, can't be re-processed by liver and sent to gut… so “extra” goes to kidney
40
Bilirubinuria
* Conjugated bilirubin in urine (coca-colar urine)
* Unconjugated bilirubin is albumin bound (NOT WATER SOLUBLE = NOT IN URINE)
* Not in hyperbliirubinemia
41
Urine testing chart
Hemolytic disease, hepatic disease, and biliary obstruction
42
Albumin
What, function, decreased levels indication
* Protein made in liver
* Helps keep fluid in blood stream and not leak out of blood stream into tissues → edema, ascites
* Helps carry nutrients and hormones throughout body
* Bound to unconjugated bilirubin
* **Low levels = severe liver disease** (late finding)
* Edema, ascites, trouble with drug metabolism/excretion
43
Ammonia
High levels indicate…
* Waste product of intestinal bacteria
* Broken down in liver → urea + glutamine
* If liver damaged → ammonia buildup → hepatic encephalopathy
* Lethargy, agitation, disorientation → coma if untreated
* Give lactulose to bind to ammonia and excrete in stool
44
Prothrombin time (PT)
Longer PT indication
* Measures time required for prothrombin to be converted to thrombin
* Dependent on Vitamin K which is stored in liver
* Non-functioning liver cannot carry out this process leading to prolonged PT and bleeding risk and clotting irregularities
45
Alpha fetoprotein (AFP)
* Tumor marker in adults…should only exist in small amounts
* Made in fetus liver and yolk sac (decreases after age 1)
* Increased in hepatocellular carcincoma
* Get serial levels to follow cirrhosis patients
* Increase should raise suspicion for HCC - cancer!!
* Not a screening tool for hepatocellular carcinoma but should get aFP if have cirrhosis
46
Ultrasound liver
Indications
* **First line - low cost**
* Can differentiate fatty changes vs cystic lesion vs solid lesion
* Fatty liver
* Screen for lesion
* BEST FOR GALLSTONES
* Gallbladder polyps
* **Not invasive**
* Can do in pts w/o s/s
* Abnormal → MRI
47
Fibro scan (Elastography)
Indication
* U/S of liver that detects fibrosis
* Used as surveillance in those with **known fibrosis (degree of)**
48
Liver MRI
Indications
* **Gold standard imaging for the liver**
* Indications
* Fatty liver
* Cyst, lesion
* Biliary duct dilation
* Choledocholithiasis
* Angioma, tumor
49
Liver CT
Indications
* Best if need image of entire abdomen
* Generalized abd pain
* Pelvic CT - appendicitis, gyn abnormality
* Indications
* Fatty liver
* Cyst, lesion
* Biliary duct dilation
* Choledocholithiasis
* Angioma, tumor
50
Gallbladder function and process
* Stores bile made from liver → releases bile to cystic duct → common bile duct → small intestine to aid in digestion
51
Gallstone conditions
* Result of too much cholesterol or too few bile salts
* Cholelithiasis - presence of too much gallstones
* Cholecystitis - inflammation of gallbladder
* Biliary colic - intermittent symptoms fo cholecystitis
52
Gallbladder workup + tx
* RUQ pain? Associated with fatty food?
* RUQ U/S
* LFTs
* Lipase
* CBC
* Surgery? gallbladder removal as there were too many stones
* Infection? more urgent!!!
53
Gallbladder workup + tx
* RUQ pain? Associated with food? What types of food? (fatty)
* RUQ U/S
* LFTs
* Lipase
* CBC
* Surgery? gallbladder removal as there were too many stones
* Infection? more urgent!!!
54
No gallbladder?
Difficulty digesting fats. Bile released into small intestine → bile salt diarrhea
55
Pancreatitis causes and acute symptoms
* Gallstones, choledocholithiasis (stones in common bile duct)
* Heavy EtOH use (acute or chronic)
* High TGs
* Acute?
* Acute LUQ, epigastric or periumbilical pain, starts intermittent → constant → N/V + worse after eating and w/lying down
56
Pancreatitis lab workup
* Labs: CBC, CMP, UA, lipase, LDH, TGs
* Lipase: pancreatic enzyme, more sensitive and specific than amylase
57
Pancreatitis imaging
U/S 1st line → Abd CT
58
Hepatitis A testing
HAV IgM, HAV IgG, Total
* Test for anti-HAV immunoglobulin
* HAV IgM (+) = acute infection - should only be ordered if symptoms acute
* Presents 3-4 weeks after exposure, normalize within 8 weeks
* HAV IgG (+) = past infection or immunity (develop **2 weeks post infection** after IgM increases and **last 10 years** post infection)
* Total HAV antibody - does not distinguish between IgG and IgM
59
Hepatitis A pathology
Transmitted via fecal-oral route or through contaminated food or water - contagious
Symptoms: fatigue, N/V, upper abd pain jaundice, dark urine, itching
**Not chronic - only acute**
Vaccine - after 2006 - get one if traveling to underdeveloped country
60
Hepatitis B pathology
Vaccine
Transmitted through blood and bodily fluids, needles, sexual contact
More asymptomatic, contributing to **silent spread**
* Can be **mild and resolve** or **become chronic**
* **If not cleared after ∼6 months = chronic**
* Vaccine
* Given to all infants at birth
* At risk pops: healthcare workers, ESRD, DM, Hep C, HIV…
* 3 dose series
* Antibody titers confirm immunity/response to vaccine
61
Hepatitis B markers
what do each indicate?
* Hep B surface **antigen**
* Presence implies **acute or chronic infection**
* **Person is _infectious_ → able to spread virus as it's in system**
* Hep B *surface **antibody***
* Indicates **recovery and immunity** from Hep B infection
* Develops after vaccination
* Does not develop in chronic carries - ACUTE
* Hep B *core* **antibody**
* Appear 4 weeks after infection and **persist for life**
* Only present if prior infection, will not develop post vaccination
* Implies **prior or chronic infection**
* Hep B IgM **antibody** (IgM andti-HBc)
* Occurs with acute infection
* Lasts for 6 months
* Positive implies infection within last 6 months
62
Hepatitis B scenarios (slide 5)
63
Hepatitis C pathology
Screening
* Transmitted through blood/bodily fluids
* No vaccine available
* **1x lifetime screen for all adults aged ≥ 18 years**
* Screening for all pregnant women during each delivery
64
Hepatitis C markers
HCV antibody test + HCV RNA + Viral genotyping
* HCV **antibody test**
* Reactive or non-reactive
* Can take 4-10 weeks to become positive - be sure to **retest**
* Remains **positive for life** - can develop it again
* Will be **_positive in person who had it already in past_**
* If someone has **no hx of Hep C infection - use this test** to confirm
* HCV RNA
* Ordered to confirm (+) HCV antibody test
* Once infection **tx/resolved → negative**
* Viral genotyping ordered for + HCV RNA
* Determine type and length of tx
