Hepatology: LFTs

Question 1

The following LFT results indicate a problem in which area of the body?

High AST
High ALT
Very high ALP
Very high GGT
Normal PT

Blood
Hepatocytes
Bones
Intestines
Biliary tree

Answer 1

Biliary tree

The correct answer here would be the biliary tree. High ALP and GGT, out of proportion with AST/ALT, suggests a cholestatic cause such as bile duct obstruction. ALP can also be high in bone disease and GGT can also be high with alcohol or phenytoin use, but together with other results, biliary tree obstruction is more likely.

Question 2

The following LFT results would most likely indicate a problem in which area of the body?

Very raised ALT
Raised AST
Slightly raised ALP
Slightly raised bilirubin
Slightly raised GGT
Prolonged PT

Intestines
Hepatocytes
Bones
Blood
Biliary tree

Answer 2

Hepatocytes

A raised ALT/AST, out of proportion with ALP and bilirubin, suggests a hepatocellular origin. This is further reinforced by the prolonged PT which can occur when a damaged liver can no longer make plentiful clotting factors.

Question 3

When ALT>AST, what are two most likely causes? [2]

Answer 3

acute viral hepatitis or acute drug toxicity

Question 4

When AST>ALT, what is the more likely pathology? [1]

Answer 4

When AST>ALT, cirrhosis is more likely.

Question 5

Paul is a 47-year-old with a long history of alcohol abuse.

Which of the following LFT results would be most likely?

Very high AST, high ALT, high GGT
Very high AST, high ALT, low GGT
High AST, very high ALT, high GGT
Low AST, high ALT, high GGT
High AST, very high ALT, low GGT

Answer 5

Paul is a 47-year-old with a long history of alcohol abuse.

Which of the following LFT results would be most likely?

Very high AST, high ALT, high GGT
Very high AST, high ALT, low GGT
High AST, very high ALT, high GGT
Low AST, high ALT, high GGT
High AST, very high ALT, low GGT

In alcohol abuse, the AST is typically much higher than the ALT.

Question 6

How does pancreatic cancer present in LFTs? [3]

Answer 6

Raised cholestatic LFTS:
- Raised ALP, GGT & bilirubin

Question 7

Which liver enzyme is liver specific? [1]

Answer 7

ALT

Question 8

AST is found in the liver and which other tissue? [3]

Answer 8

Heart, muscle & kidney

Question 9

ALP is released from which tissues? [3]

Answer 9

Bile cannalicluar
Bone
Placenta

Question 10

Which liver enzyme is particularly raised in patients with alcohol excess? [1]

Answer 10

GGT

Question 11

The AST:ALT ratio of WHAT indicates alcoholic liver disease? [1]

Answer 11

AST:ALT > 2:1

Question 12

ALP and GGT are interpreted together to localise the source of raised ALP in the blood:

An ALP rise with normal GGT suggests []

An ALP rise with associated GGT rise is more suggestive of []

Answer 12

An ALP rise with normal GGT suggests bone disease (e.g. Paget’s disease, vitamin D deficiency, bony metastases)

An ALP rise with associated GGT rise is more suggestive of cholestasis

Question 13

An isolated GGT rise is classically associated with []

Answer 13

An isolated GGT rise is classically associated with alcohol excess.

Question 14

Severe liver disease leads to decreased production of clotting factors and an [increased or decreased] prothrombin time (PT) / INR in the absence of other causes of coagulopathy?

Answer 14

Severe liver disease leads to decreased production of clotting factors and an increased prothrombin time (PT) / INR in the absence of other causes of coagulopathy.

Question 15

Combination of which blood function liver tests would suggest severe liver disease?

Answer 15

Elevated bilirubin & liver enzyme

Question 16

What are the categories of tests are involved in liver screen? [4]

Answer 16

Viral Screen
Immunoglobulins
Autoantibodies
Metabolic

Question 17

Which immunoglobulins are specifically screened for in a liver screen? [3]
Which diseases do they indicate may be more likely?

Answer 17

IgA: ALD
IgM: Primary biliary cholangitis (PBC)
IgG: Autoimmune hepatitis

Question 18

Which auto-antibodies are specifically screened for in a liver screen for:

• PBC [2]
• AIH [3]
• PSC [1]

Answer 18

PBC: -
- AMA (anti-mitochondiral antibody):
- AMA M2 antibody

AIH:
- ANA (Antinuclear antibody);
- SCM (smooth muscle antibody);
- SLA (soluble liver antigen)

PSC:
- ANCA (Antineutrophilic cytoplasmic antibody)

Question 19

Which metabolic markers in a viral screen indicate that a patient is suffering from:

• NAFLD [2]
• Haemochromatosis [2]
• Wilson’s disease [1]
• A1AT [1]

Answer 19

NAFLD (high association with metabolic syndrome)
* Elevated Lipids;
* Elevated fasting sugar

Haemochromatosis
* Raised ferritin
* HFE homozygous

Wilson’s disease
* Low caeruloplasmin

A1AT:
* Presence may increase chance of alcohol related injury if a carrier

Question 20

How can you ID if there is focal liver scarring or if there is focal liver lesion (cancer)? [2]

Answer 20

Percutaneous liver biopsy
Transjugular liver biopsy (less pain; reduced risk)

Question 21

Describe what is an ECRP procedure? [3]

Answer 21

Endoscopic Retrograde Cholangio Pancreaticography:
- Endoscopy under fluroscopic guidance of biliary tree and pancreatic tree (dye of each structure)
- Diagnose to ID block of each tree
- Therapy: stent / tube to open blockage

USED AFTER MRCP as more invasive

Question 22

Describe the process of TIPS [2]

Answer 22

• shunt inserted into portal vein & into hepatic circulation
• reduces portal pressure

Question 23

When is TIPS indicated? [2]

Answer 23

Treat bleeding in varices due to portal HTN
Ascites refractory to medical therapy

Question 24

TIPS increases the risk of which pathology? [1]

Answer 24

Hepatic encephalopathy