LFTs Flashcards
What were the four herbals/ vitamins listed that are common for drug induced liver injury
Ephedra
Kava
Vitamin A
Garcinia cambogia
Your worst nightmare has come true, and you are working in peds. A parent brings in their child and they have neonatal cholestasis. Obviously their ALT/AST is elevated because it’s liver stuff. What special test are you going to order for this tiny monster
Serum a-1 antitrypsin
Probably has alpha-1 antitrypsin deficiency due to having liver disease as a freakin baby
A-1 antitrypsin phenotype if their insurance will cover it
Name that stage of nonalcoholic fatty liver disease
Fibrosis of the liver
Cirrhosis
Your patient has signs of liver disease, low serum ceruloplasmin, but you don’t see any Kayser-Fleischer rings. You do a 24 hour urine copper test and it is normal.
Whatchu got?
Need more tests?
Obtain a liver biospy or genetic testing
Serum ceruloplasmin was low, still need to confirm
What enzyme would be elevated in diseases affecting the biliary tree
5NP
Tests that refelct liver FUNCTION
Albumin
PT/INR
What are the three progressions of Nonalcoholic Fatty Liver Disease
- Simple Steatosis (NAFL)
- Non-alcoholic steatohepatitis (NASH)
- Cirrhosis
Transmission method for Hep B
Blood
Sexual contact
Birth
What could be the cause of AST elevation on its own
Skeletal muscle
Cardiac muscle
Kidney
Brain
How does Hep C classically present
Aysymptomatic 85% of the time
Some people get jaundice and fatigue fever, etc
Most people with hereditary hemochromatosis are asymptommatic, maybe with some fatigue and decreased libido. However, if they reach later stages of the disease, what are some signs and symptoms:
- Cirrhosis of the liver
- Bronze skin
- Cardiomegaly —-> Heart failure
- Diabetes (pancreas)
- Impotence (gonads)
ALL OF THESE THINGS DUE TO IRON DEPOSITING IN THAT ORGAN
When you have a super high ALP and GGT and you know its liver origin, What can tell you if it is alcoholic liver disease
If AST:ALT ration is MORE THAN 2:1
More AST!!! Even though its liver!!!
All the youtube videos said this was ~HiGh YiElD~
Which Hep is associated with Baby boomers
Hep C
Wilsons disease:
ALT/AST:
ALP:
ceruloplasmin:
24 hour urinary copper:
ALT/AST: elevated
ALP: low
Cerulosplasmin: low
24 hour urinary copper: high
How do you diagnose non alcoholic steatohepatitis
Mildly elevated AST and ALT
Confirm fatty infiltration with fibroscan or liver biopsy
What could be the cause of ALP elevated on its own
Bone
Preggo
Intestines
Hep B testing interpretation:
HBsAg = -
Total anti-HB= -
Anti-HBs = -
Susceptible to Hep B infection- never had it, no vaccine
ALT/AST = mild ALP = very high ANA = + AMA = -
What disease?
Primary Sclerosing Cholangitis
Transmission method for Hep A
Fecal-oral
Say no to rim jobs, kids.
Hep B testing interpretation:
HBsAg = -
Total anti-HB= +
Anti-HBs = +
IgG anti-HBc= +
Immune due to natural infection
Had it and got better
Of the hepatitis category (A B and C) which one has the smallest increase in ALT/AST
Hep C
In suspected HCV, you test for HCV antibody and it was reactive, and then you test for HCV RNA and it was detected, what next?
They have current HCV infection — treatment
When would someone with wilsons disease present with symptoms
5-35
What could be the reason LDH is elevated on its own
Tissue necrosis
Hep B testing interpretation:
HBsAg = +
Total anti-HB= +
Anti-HBs = -
IgM anti-HBc = -
Chronically infected
You get a high ALP, but you know that could be either liver OR something else. What other test can you look at to confirm liver origin
GGT
You patient has signs of liver diease, serum ceruloplasmin is low, AND there are Kayser-Fleischer rings in their eyes. You decide to do a 24 hour urine copper test and it comes back HIGH AS HELLLLLL
Whatchu got?
Need more tests?
Wilsons, the diagnosis is established
What % of people who get acute Hep C get chronic Hep C?
70-80%
If a patient haws elevated LFTs but no symptoms, what next?
Repeat the test - fasting
Which stage of Nonalcoholic fatty liver disease:
Fatty liver without inflammation, low risk of developing significant fibrosis
Non-alcoholic fatty liver (NAFL)
Stage 1
What % of people who have acute Hep A get chronic hep A
Chronic Hep A doesn’t exist. So zero.
Hep B testing interpretation:
HBsAg = -
Total anti-HB= -
Anti-HBs = +
Immune because you are smart and got a vaccine
How long does it take to recover from Hep A?
6 months
Hemochromatosis is _____ build up in the liver
Iron
Hep B testing interpretation:
HBsAg = +
Total anti-HB= +
Anti-HBs = -
IgM anti-HBc= +
ACUTE ACUTE!
They got that ish right nowwwww
Your patient has signs of liver disease, normal serum Ceruloplasmin and Kayser-Fleischer rings.
Whachu got?
Need more tests?
Go straight to the biopsy without the urine test. Even if the urine test came back positive, you can’t diagnose with normal serum and high copper urine for wilsons, you need the biopsy.
What is the cause of 45% of deaths for people with hereditary hemochromatosis ??
How do you detect this?
Hepatocellular carcinoma
Screen using AFP (alpha fetoprotein) and ultrasound
What are some things not fully discussed in the lecture that could end up on a differntial for elevated ALT/AST (but not super elevated like a chronic disease)
Cancer
Celiac disease
Chronic alcoholic hepatitis
Things we talked about: Drug induced liver injury (also could be in the acute differential with high values!) Fatty liver Hemochromatosis Autoimmune hepatitis Alpha-1 anti-trypsin deficiency Wilsons disease
You test for HCV antibody and it is reactive, so you test for HCV RNA and it is not detected. What next?
No further action required, probably a false positive on the antibody
Which labs reflect hepatocellular damage
ALT
AST
Hep B testing interpretation:
HBsAg = -
Total anti-HB= +
Anti-HBs = -
~iNtErPrEtAtIoN uNcLeAr~
- Most likely a resolved infection even though the anti-HBs is negative
- Could be a false positive anti-HBc, which means they are susceptible (never had it or the vaccine)
- “Low level” chronic infection even though HBsAg is negative
- Resolving acute infection
H/H: low
AST/ALT: normal
Indirect Bilirubin: elevated
Direct Bilirubin: normal
Whatchu got
Hemolysis
Also see an increased retic count and abnormal peripheral smear
Which Hep is associated with drug use, tattoos, high risk sexual behavior, etc
(Just think like times square in the early 90’s that should cover all the risk factors)
Hep C
Hepatomegaly, Tremors, dysarthria, incoordination, personality or behavioral changes in someone ages 5-35 makes you think of what tests to order? For what disease?
Serum ceruloplasmin
24 hour copper urine
Look in their eye for kayser-fleischer rings
WILSONS
Hep B
ALT/AST:
ALP:
Bilirubin:
Hep B
ALT/AST: BIG INCREASE
ALP: increase
Bilirubin: increase
Which labs refect cholestatic process
ALP
Total bilirubin
GGT
Your patient has signs of liver disease, no Kayser-Fleischer rings, and a normal serum ceruloplasmin. You do a 24 hour urine copper test anyway even tho how would you even think to do that but whatever, and it comes back HIGH AS HELLLL
Whachu got?
Need more tests?
Obtain a liver biopsy or genetic test for Wilson’s disease
*can’t confirm with just the urine since serum ceruloplasmin was normal
In suspected Hep C, you test for HCV antibody and it is nonreactive, what next?
No further action required but if recent exposure within the last 6 month or is suspected OR if they are immunocompromised, test for HCV RNA
Which two antibodies do you test for with suspected Hep C
HCV antibody HCV RNA (not really an antibody tho)
H/H: normal
AST/ALT: normal
Indirect Bilirubin: elevated
Direct Bilirubin: normal
Whatchu got
Gilbert’s syndrome
In suspected HCV, you test HCV antibody and it is reactive, what next?
Test for HCV RNA
When determing if an infection is acute or chronic, lab values would be ___x the normal amount for a cute, and less than that for chronic
5 times
What % of adults who get acute Hep B end up with chronic Hep B
Only 5%
LABS for hereditary hemochromatosis
Ferritin:
Transferrin:
TIBC:
ALT/AST:
Ferritin: INCREASED
Transferrin: INCREASED
TIBC: DECREASED
ALT/AST: ~MiLd~ increase
Which autoimmune diseases are hepatocellular?
Which autoimmune diseases are cholestatic?
Hepatocellular = autoimmune liver disease
Cholestatic = primary biliary cirrhosis, primary sclerosing cholangitis
ALT/AST = very high ALP = mild ANA = + ASMA = very high LKMA = +
What disease?
What antibody titer would you find?
Autoimmune liver diease
IgG
Your patient has signs of liver damage, low serum ceruloplasmin, and Kayser-Fleisher rings, so you do a 24 hour urine copper test that comes back normal.
Whachu got?
Need more tests?
Liver biopsy or genetic testing to establish wilsons disease
*can’t confirm without the biopsy or genetic test because urine test was normal
Kayser-Fleischer rings are NOT enough for diagnosis!
If you get a value that is SUPER HIGH for ALT/AST, other than the obvious acute hepatitis that you should be thinking of… what else is on the differential
Epstein-Barr virus Cytomegalovirus Acute Alcoholic Hepatitis (not chronic!) Drug Induced Liver Injury Mushroom ingestion Acute Hepatitis of pregnancy (????) Shock liver (hepatic ischemia)
Primary Sclerosing Cholangitis
Men or women
Men
How long is someone with Hep A contagious?
Thru the entire incubation period which averages 28 days + 1 week after symptoms of JAUNDICE
What is unique about Hep B’s presenting symptoms
Usually without jaundice!
(Anicteric) even though bilirubin is increased
Autoimmune Liver disease:
Men or women
Women
Your patient has signs of liver disease, low serum ceruloplasmin, but you don’t see any kayser-fleischer rings. You do a 24 hour urine copper test and it comes back SKY HIGH
Whachu got?
Need more tets?
Wilson’s diagnosis is established
YOU DO NOT NEED THOSE DAMN RINGS TO ESTABLISH DX! If you have low serum ceruloplasmin, and high urine copper that is enough
What percent of small children who get hep B end up with chronic hep B
25-50%
What % of infants who get hep B end up with chronic hep B
90%
That SUCKS
ALT/AST = mild ALP = very high ANA = + ASMA = mild AMA = very high LKMA = -
What disease?
What antibody would you find?
Primary Biliary Cirrhosis
IgM
Hep A
ALT/AST:
ALP:
Bilirubin:
Hep A
ALT/AST: VERY MUCH INCREASED
ALP: increased
Bilirubin: increased
Your patient has signs of liver disease, no Kayser-Fleischer rings, and a normal serum ceruloplasmin. You do a 24 hour urine copper test anyway because i dunno you felt like it, and it comes back normal
Whachu got?
Need more tests?
Wilson disease is excluded
All that ish was negative so you need to get off this wilsons thing and start thinking of other stuff it could be
How long is the anti-HAV IgM that is diagnostic for Hep A positive in the serum?
4 months after symptoms appear
Symptoms usually appear a month after infection, due to incubation period
What is the treatment for Hereditary hemochromatosis
AVOID GETTING CIRRHOSIS!!!!!!!!
- Don’t take vitamin C (for whatever fucking reason) 🍊🍊
- Don’t take iron supps (ok that makes sense) 🥩
- Don’t eat raw seafood (??????? What the actual fuck) ;🍣🍣🍣
- Don’t drink alcohol (also makes sense) 🥃🍸🍺
- BLOOD LETTING 💉💉
- Get immunizations for Hep A and B
Primary Biliary Cirrhosis
Men or women
Women
A patient comes in with emphysema and they are 44 years old. You start to judge them for being a chain smoker because why else would they have emphysema at 44 years old.
Then they tell you they have never smoked a cigarette in their entire life.
What test do you order STAT
…maybe not STAT. It can wait a few days whatever
AST/ALT = mild elevation
Serum a-1 antitrypsin = decreased
A-1 antitrypsin phenotype if their insurnace will pay for genetic testing (they wont)
Because they have alpha-1 antitrypsin deficiency
Which stage of nonalcoholic fatty liver disease:
Fatty liver + inflammation with hepatocyte injury
High risk of developing significant fibrosis
Non alcoholish steatohepatitis (NASH)
Management of nonalcoholic fatty liver disease includes:
Weight loss
No alcohol
Control diabetes and cholesterol
If cirrhosis = transplant
What are the 4 risk factors for nonalcoholic fatty liver disease
- Abdominal obesity (big ole beer belly)
- Insulin resistance DM
- Hyperlipidemia
- Metabolic syndrome
What is the strongest predictor of nonalcoholic steatohepatitis (NASH)
Metabolic syndrome
