Liver 101 - Jess Davies teaching

Question 1

Where is ALT produced?

Answer 1

Liver and muscle

Question 2

When might ALT be increased?

Answer 2

Liver pathologies

Also other muscle things like rhabdomyolysis

Question 3

Where is AST produced?

Answer 3

Liver, muscles, RBCs

Question 4

What would the ratio of ALT to AST be if the pathology was specific to the liver?

Answer 4

ALT>AST

Question 5

Where is ALP produced?

Answer 5

Liver, bone & placenta

Question 6

When is ALP elevated?

Answer 6

Elevated in OBSTRUCTIVE disease

Question 7

Where is GGT produced?

Answer 7

Just after liver?

Question 8

When is GGT elevated?

Answer 8

Elevated in OBSTRUCTIVE disease

Question 9

When is bilirubin elevated?

Answer 9

Obstruction
Haemolysis
Acute hepatitis
Cirrhosis

Question 10

What’s elevated in obstruction?

Answer 10

ALP
GGT
Bili

Question 11

What are synthetic liver function tests?

Answer 11

Albumin
aPTT
PT

Question 12

What stuff does the liver synthesise?

Answer 12

Thrombopoietin 
Bile salt
Lipid metabolism 
Glycogen storage and release
Protein synthesis and metabolism 
Bilirubin conjugation, excretion and recycling
Hormone inactivaiton 
Drug metabolism 
Essential in innate immunity

Question 13

What hormones does the liver inactivate?

Answer 13

Oestrogen
Glucagon
Insulin
Glucocorticoids
PTH
NOTE: also converts Cholecalciferol —> 25hydroxycholecalciferol

Question 14

Which protein does the liver not synthesise?

Answer 14

Immunoglobulins

Question 15

Causes of acute hepatitis

Answer 15

Viral hepatitis
Autoimmune hepatitis
Acute drug induced liver injury (DILI)
Alcoholic hepatitis

Question 16

What would the ALT to AST ratio be in acute hepatitis?

Answer 16

Acute hepatitis will give you a significant rise in transaminases (a transaminitis), with ALT&raquo_space;AST

Question 17

What would the ALT to AST ratio be in alcoholic hepatitis? i.e. exception to acute hep rule?

Answer 17

AST 2.5 x greater than ALT

Question 18

Symptoms and signs of viral hepatitis

Answer 18

Fever
Malaise
Jaundice
Hepatomegaly 
Anorexia

Question 19

What would you screen for in autoimmune hepatitis, type 1?

Answer 19

NOTE: you'd also screen for immunoglobulin levels 
ANA
ASM (MAIN ONE)
AAA (anti actin)
anti-SLA (soluble liver antigen)

Question 20

What would you screen for in autoimmune hepatitis, type 2

Answer 20

NOTE: you’d also screen for immunoglobulin levels
Anti liver/kidney microsome 1 (anti-LKM1)
Antibody to liver cytosol antigen (ALC-1)

Question 21

What drugs might cause acute drug induced hepatitis?

Answer 21

Antibiotics
Antivirals
Immunosuppressants

Question 22

Symptoms of liver cirrhosis

Answer 22

Malaise/fatigue
Bruising/bleeding easliy 
Anorexia/weight loss
Feeling of enlarged abdomen 
Swollen legs/belly 
Jaunice itch (pruittis) 
Hand tremors

Question 23

Signs of liver cirrhosis

Answer 23

Spier naevi 
Palmar erythema
Bruises
Hepatosplenomegaly 
Ascites 
Jaundice 
Xanthoma
Finger clubbing 
Caput medusae 
Gynecomastia
Fever
Leukonichia 
Thigh oedema
Encephalopathy 
Purpura 
Hepatic halitosis 
Hepatoceleoma

Question 24

What is hepatic halitosis?

Answer 24

Ketones in breath

Question 25

What would suggest synthetic dysunction?

Answer 25

Low albumin (below 28 = poor prognosis)
High PT and aPTT

Question 26

What else might AST>ALT suggest

Answer 26

Decompensated alcoholic cirrhosis

Question 27

What might the FBC show in liver disease and why?

Answer 27

Anaemia
Low platelet time?
Low white cell count (splenomegaly)

Hyponatremia
High creatinine hepatorenal syndrome)

Hyperglycemia