LFTs

Question 1

AST:ALT in alcohol damage/cirrhosis

Answer 1

AST:ALT
2.5:1
(Ratio = >1)

Question 2

AST:ALT in viral damage

Answer 2

AST:ALT
1:1
(Ratio = <1)

Question 3

AST + ALT found in which cells

Answer 3

Hepatocytes

Question 4

GGT found where?

Answer 4

Hepatocytes and walls bile ducts

Question 5

GGT elevated in:

Answer 5

Chronic alcohol use (along with AST/ALT)
Acute large alcohol intake
Bile duct disease and hepatic mets (with ALP)
(also can be raised in extra-hepatic diseasE)

Question 6

ALP raised in

Answer 6

Obstructive jaundice
Bile duct damage
(also bone disease, pregnancy)

Question 7

Liver tumour marker

Answer 7

Alpha-Fetoprotein
Raised in hepatocellular carcinoma

Also can be raised in:
Hepatic damage
Pregnancy
Testicular Cancer

Question 8

What is the major protein synthesised by the liver?

Answer 8

Albumin

- Contributes to oncotic pressure and binds steroids / drugs / bilirubin / calcium etc

Question 9

When is albumin low?

Answer 9

Low production (chronic liver disease, malnutrition)
Loss (gut, kidney)
Sepsis (“3rd spacing”)

Question 10

Best acute marker of liver function?

Answer 10

Prothrombin time

as liver stops producing clotting factors

Question 11

Bilirubin breakdown process

Answer 11

Heamoglobin > Heam > Br
Br > Liver (Br conjugated here)

Conj Br > Out of liver into Intestines with bile
At intestines (ileum) = Br > Urobilinigen by bacteria

Then in ileum:

1) 90% oxidised by bacteria to stercobilinogen
2) 10% absorbed and carried to kidneys and excreted as urobilinogen

(If obstructive jaundice - more is left as Conjugated and not further processed properly = dark urine, pale stools)

There should be no urobilinigen in urine in obstructive jaundice)

Question 12

A 24 year old male medical student noticed that his sclera went yellow after an end of term party. He has noticed this a few times. He occasionally binge drinks but denies other drugs. He is not on any medication. There are no abnormalities on examination and no bilirubinuria on dipstick testing

Bilirubin	36umol/L (<17)
Albumin  	40g/L (35-51)
ALT	            35 IU/L (<40)
AST	            36 IU/L (<40)
ALP	            38 IU/L (35-51)
GGT	            35 IU/L (11-42)

What is the diagnosis?

Haemolytic anaemia
Gilbert’s syndrome
Gall stones
Viral Hepatitis
Alcoholic Hepatitis

Answer 12

Gilbert’s

Common, found in 3-10% of population
Deficiency in glucoronyl transferase, enzyme involved in conjugating bilirubin
Stress on liver → increase in unconjugated bilirubin
All other LFTs will be normal – excludes hepatic and post-hepatic causes
Blood film normal – excludes pre-hepatic causes

Question 13

What type of Br would be found on urine dip in obstructive jaundice?

Answer 13

Conjugated (no urobilinogen)

Question 14

What should you be suspicious of in isolated rises of LFT OTHER than liver pathology?

Answer 14

Br = Gilbert’s, haemolysis, haematoma, intra-abdominal bleeds

AST/ALT = skeletal muscle, cardiac muscle, kidneys and RBC

ALP = Bone, placenta, kidneys, intestine

GGT = kidney, pancreas, spleen, heart, brain

Question 15

Enzyme which converts unconj-conjugated Br?

Answer 15

Glucoronyl transferase

Question 16

74 year old retired publican presents with a 3-week history of itch, pale stools, dark urine and yellow sclera. He has a 2-month history of weight loss. On examination he is jaundiced with no signs of chronic liver disease. Bilirubinuria is noted on urine dipstick.

Bilirubin	120umol/L (<17)
Albumin	29g/L (35-51)
ALT	            36 IU/L (<40)
AST	            45 U/L (<40)
ALP               450 U/L (35-51)
GGT	            98 U/L (11-42)

What is the diagnosis?

Gallstones
Gilbert’s syndrome
Pancreatic cancer
Viral Hepatitis
Alcoholic Hepatitis

Answer 16

Pancreatic Cancer

Painless jaundice
Courvoisier’s law “…….in the presence of a painless palpable gallbladder, jaundice is unlikely to be caused by gall stones…”

Gallstones are formed over an extended period of time, resulting in a shrunken, fibrotic gallbladder which does not distend easily and is less likely to be palpable on examination

Gallbladder is more often enlarged and thus more easily palpated in pathologies that cause obstruction of the biliary tree over a more acute, shorter period of time

Question 17

An 18 year old female art student came in with jaundice. She had been feeling terrible with fevers, diarrhoea, joint pain, and turned yellow in the last 2 days. She had returned from trip to Goa 2 weeks previously. She has no significant PMH and took anti-malarial tablets for prophylaxis. On examination she is jaundiced and there are no signs of chronic liver disease.

Bilirubin	168umol/L (<17)
Albumin 	38g/L (35-51)
ALT	            2500 IU/L (<40)
AST	            2380 U/L (<40)
ALP	            190 U/L (35-51)
GGT	            39 U/L (11-42)

What is the diagnosis?

Gallstones
Gilbert’s syndrome
Pancreatic cancer
Viral Hepatitis
Alcoholic Hepatitis

Answer 17

Viral Hepatitis

Hep A
RNA virus
Spread by faecal-oral transmission. Areas of high prevalence have poor sanitation and hygiene
HAV survives for extended periods in sea water, fresh water, waste water, and soil
Average incubation period is 28 days

Question 18

An 18 year old male art student came in with jaundice. He has not had any other symptoms. He had returned from trip to Goa a day ago and took anti-malarial tablets for prophylaxis. He reports having a few episodes of jaundice when he was younger. On examination he is jaundiced and there are no signs of chronic liver disease.

Bilirubin	168umol/L (<17)
Albumin 	38g/L (35-51)
ALT	             38 IU/L (<40)
AST	             32 U/L (<40)
ALP	             38 U/L (35-51)
GGT	             12 U/L (11-42)

What is the diagnosis?

G6PD deficiency
Gilbert’s syndrome
Sickle Cell Disease
Hereditary spherocytosis
Drug-induced hepatitis

Answer 18

G6PD deficiency

X-linked inheritance
Protective effect against P. falciparum and P. vivax malaria hence more prevalent in endemic areas

First step in pentose phosphate pathway → involved in producing molecules which mop up free radicals

Deficiency leads to increased RBC death by oxidative damage → damaged RBC get mopped up in the spleen → haemolysis
Triggers: drugs (sulphonamides and anti-malarials), fava beans, henna → avoid these

Question 19

A 69 year old man comes to the A&E with a 3 day history of ascites. He has been feeling quite tired and nauseated for the past week, and his wife has noticed that he has been looking quite yellow for a few weeks. On examination, he has hepatomegaly and some spider naevi on his chest. On further questioning he reports that he drinks 8 units of alcohol a day.

Bilirubin	200umol/L (<17)
Albumin 	28g/L (35-51)
ALT	             2500 IU/L (<40)
AST	             2900 U/L (<40)
ALP	             170 U/L (35-51)
GGT	             90 U/L (11-42)

What is the diagnosis?

Gallstones
Gilbert’s syndrome
Pancreatic cancer
Viral Hepatitis
Alcoholic Hepatitis

Answer 19

Alcoholic Hepatitis

With signs chronic liver disease

Question 20

A 47 year-old obese woman comes in with a sharp stabbing pain at her liver area which started coming on after her lunch. She feels nauseated. She has also reported her stools are grey in colour and her urine is much darker since yesterday.

Bilirubin	200umol/L (<17)
Albumin 	32g/L (35-51)
ALT	             42 IU/L (<40)
AST	             45 U/L (<40)
ALP	             210 U/L (35-51)
GGT	             90 U/L (11-42)

What is the diagnosis?

Gallstones
Primary Biliary Cirrhosis
Primary Sclerosing Cholangitis
Pancreatic Cancer
Cholangiocarcinoma

Answer 20

Gallstones