LFTs Flashcards
AST:ALT in alcohol damage/cirrhosis
AST:ALT
2.5:1
(Ratio = >1)
AST:ALT in viral damage
AST:ALT
1:1
(Ratio = <1)
AST + ALT found in which cells
Hepatocytes
GGT found where?
Hepatocytes and walls bile ducts
GGT elevated in:
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)
ALP raised in
Obstructive jaundice
Bile duct damage
(also bone disease, pregnancy)
Liver tumour marker
Alpha-Fetoprotein
Raised in hepatocellular carcinoma
Also can be raised in:
Hepatic damage
Pregnancy
Testicular Cancer
What is the major protein synthesised by the liver?
Albumin
- Contributes to oncotic pressure and binds steroids / drugs / bilirubin / calcium etc
When is albumin low?
Low production (chronic liver disease, malnutrition)
Loss (gut, kidney)
Sepsis (“3rd spacing”)
Best acute marker of liver function?
Prothrombin time
as liver stops producing clotting factors
Bilirubin breakdown process
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)
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
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
What type of Br would be found on urine dip in obstructive jaundice?
Conjugated (no urobilinogen)
What should you be suspicious of in isolated rises of LFT OTHER than liver pathology?
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
Enzyme which converts unconj-conjugated Br?
Glucoronyl transferase
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
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
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
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
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
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
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
Alcoholic Hepatitis
With signs chronic liver disease
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
Gallstones
