Labs: Liver Disease Flashcards
A 61 year-old man lost 8 kg during the last 4 months. He complains of pruritus and frequent dull epigastric pain. He has noted dark urine, but light stools lately. He has jaundice. The gallbladder is palpable, but non-tender.
Laboratory results:
serum bilirubin: 310 μmol/l, mostly direct urine
Ubg: negative
ASAT: 82 U/l
ALAT: 91 U/l
alkaline phosphatase: 540 U/l
prothrombin time: INR = 2.6
What is the cause of his jaundice? What further tests do you consider?
Extrahepatic Biliary Obstruction: Pancreatic Head Tumor
Post-hepatic jaundice: Direct hyperbilirubinemia (>17, mostly direct/conjugated) + Courvoisier sign (enlarged, painless GB)
Other signs:
Obstruction: No UBG suggests total obstruction, dark urine and light stool, PT is long (>1.2 INR) bc Vit K not absorbed
Liver damage: ASAT/ALAT are high (>45), ALP is very high (>150)
Weight loss supports malignancy
Further tests: ERCP (endoscopy retrograde cholecystopancreatography), imaging (MRI, CT, US)
An icteric woman has the following laboratory parameters: serum indirect bilirubin: 54 μmol/l serum direct bilirubin: 5,1 μmol/l urine bilirubin: negative ASAT: 19 U/l ALAT: 22 U/l LDH: 720 U/l Ht: 0.33 l/l plasma haptoglobin and hemopexin concentrations are significantly decreased What is the cause of her jaundice?
Hemolysis-induced Prehepatic jaundice Low Ht (<0.37) + haptoglobin and hemopexin related to RBC high LDH (>160)
Cause of hemolysis unknown, maybe autoimmune intravascular (haven’t learned much about this yet)
A 38 year-old man, who regularly drinks alcohol. He has never been ill before, but he has grown icteric in the last couple of days. He has a temperature, and is a little anemic. His liver is palpable an inch below the ribs, it is slightly tender. Laboratory results: urine color: dark brown serum total bilirubin: 150 μmol/l ASAT: 160 U/l ALAT: 60 U/l GGT: 490 U/l MCV: 103 fl What is the cause of his jaundice?
Acute Alcoholic Hepatitis
Alcoholic signs: GGT elevation (>60), ASAT > ALAT while both being elevated, total bilirubin high (>17 μM)
Acute symptoms indicate not cirrhosis, earlier stage.
MCV high (>95) -> macrocytic anemia due to Vit B deficiency
A 47 year-old man has been on hemodialysis for 5 years before he got his kidney transplantation. He has little body hair, a large, protruding belly, slim extremities and gynecomastia. Laboratory results: ASAT: 85 U/l ALAT: 76 U/l prothrombin time: INR = 2.7; it does not change after vitamin K administration albumin: 28 g/l K+: 3.3 mmol/l Ht: 0.36 What is the most likely diagnosis?
Chronic Non-Alcoholic Cirrhosis + Liver Failure, prob iatrogenic hepatitis (maybe Hep C from transfusion after dialysis)
Liver failure: Signs of hyperestrogenism bc liver can’t break it down, ASAT and ALAT high (>45), low albumin (<35), low Ht (<0.4)
2° hyperaldosteronism: Ascites → ↓ circulating fluid volume → activation of RAAS in kidney → ↑ aldosterone → ↑ K+ excretion causing hypokalemia
A 38 year-old woman complains of recurrent, sharp pain in the right upper quadrant of her abdomen. She has been vomiting, has fever and jaundice.
Laboratory results:
serum bilirubin: 50 μmol/l, mostly direct
Ubg: negative
ASAT: 180 U/l
alkaline phosphatase: 640 U/l
What is the cause of her symptoms, and how can you prove the diagnosis?
Obstructive Jaundice, prob gallstone. Should perform abdominal US test to check for stone.
Post hepatic jaundice: bilirubin high (>17) and mostly direct (conjugated)
Obstruction: Fits at least some of the 4F’s (Fat, Female, Forty, Fertile) + RUQ pain, ALP high (>150), Ubg neg
Liver damage: ASAT high (>45)
A 25 year-old man has been icteric for a few days. His laboratory values: serum indirect bilirubin: 47 μmol/l serum direct bilirubin: 4 μmol/l ASAT: 18 U/l ALAT: 23 U/l alkaline phosphatase: 66 U/l Ht: 0.48 Hb: 162 g/l What is the cause of his jaundice? What further tests are necessary?
Gilbert syndrome: young, otherwise completely healthy, yet indirect (unconjugated) bilirubin is high (>17)
Gilbert is slightly decreased UDP-g transferase activity.
No further tests are really necessary, but may have patient fast for 2 days then measure indirect bilirubin - if it’s double initial measurement, Gilbert is confirmed bc stress from fasting induces rise of bilirubin
A 32 year-old man has been complaining of fatigue, malaise and a temperature for a week. His liver is palpable ¾ of an inch below the ribs, it is a bit tender. His laboratory results: serum indirect bilirubin: 28 μmol/l serum direct bilirubin: 24 μmol/l Ubg: increased ASAT: 870 U/l ALAT: 1180 U/l alkaline phosphatase: 310 U/l What is the most likely diagnosis, and how can you prove it? What further tests are necessary?
Acute Viral Hepatitis
Very high ALAT and ASAT (both >45) and ALAT > ASAT indicate viral hepatitis
Equal direct/indirect bilirubin elevation → hepatocellular jaundice. Ubg increase means no obstruction.
Prove with Hep A/B/C… antibodies.
A 28 year-old woman. She is complaining of fatigue, malaise and nausea.
serum total bilirubin: 45 μmol/l
ALAT: 220 U/l
alkaline phosphatase: 200 U/l
γ-globulins: 33 g/l (↑)
RF and ANA: positive
What is the most likely diagnosis, and what tests should be done?
Autoimmune Hepatitis, likely SLE
Bilirubin high (>17), ALAT high (>45), ALP high (>150)
RF, ANA, and gamma globulins indicate autoimmune disease
Should check other antibodies: anti-cardiolipin, anti-Smith antigen (RNA-binding protein)
Also test to rule out viral hepatitis B/C.
A 30 year-old woman, who is 164 cm tall, her body weight is 81 kg. She saw her doctor, because she had noted a yellow discoloration of her skin accompanied by itching. She mentions she has had unpleasant gastrointestinal symptoms after meals for a long time: feeling full, having nausea. Physical examination reveals: yellow skin and sclera, spleen is not palpable, liver enlarged by an inch. The right upper quadrant of her abdomen is clearly sensitive on palpation. Laboratory findings: serum bilirubin: 150 μmol/l urine bilirubin: positive Ubg: decreased ASAT: 53 U/l alkaline phosphatase: 710 U/l GGT: 390 U/l What is the most likely diagnosis?
Posthepatic obstructive jaundice, probably gallstone.
Also fits some of the 4F’s (Fat, Female, Forty, Fertile) for gallstone risk. Urine bilirubin confirms conjugated (direct) hyperbilirubinemia. Ubg decrease and GGT high (> 60) also indicate obstruction.
A newborn baby is admitted to the hospital with a complaint of increasing jaundice.
The serum bilirubin is 160 μmol/l.
What can be the cause of the jaundice if this bilirubin is mainly:
1. direct, or
2. indirect reacting?
- Direct / Conjugated: Dubin-Johnson or Rotor syndromes (or maybe infection or biliary atresia)
- Indirect / Unconjugated: Crigler-Najjar (or maybe physio jaundice, erythroblastosis fetalis, or Gilberts, but prob not)
Phototherapy can be used to solubilize excess dermal bilirubin in neonatal jaundice
