Liver Flashcards
Liver Function Tests: Most Useful
Serum bilirubin, ALP, aminotransferases (AST, ALT)
Bilirubin is seen clinically at:
> 2.5mg/dL
Newborn Jaundice: Physiological vs. Pathological
-Physiological: 2 days-2 weeks
-Pathological: First 24 hours
Prehepatic Jaundice Causes
-Excessive hemolysis*
-Extravascular hematomas
-Pulmonary infarct
Hepatic Jaundice Causes:
-Conjugation failure
-Bilirubin Transport Distrubances
Conjugation Failure
• Neonatal physiological jaundice – 50% full-term newborns
Bilirubin Transport Disturbances
-Dubin-Johnson Syndrome
-Gilbert’s Syndrome
-Diffuse Hepatocellular Damage or necrosis
-Intrahepatic obstruction
Dubin-Johnson Syndrome
Post-conjugation bilirubin transport failure (post-hepatic)
Gilbert’s Syndrome
-Pre-conjugation bilirubin transport failure
-Fast: 24-48 hours
-Unconjugated bilirubin (2x)
Diffuse Hepatoceullular Damage or Necrosis: Acute vs. Chronic
-Acute: Viral hepatitis & Alcohol/drug induced liver cell injury
-Chronic: Active cirrhosis, liver tumor, biliary cirrhosis
Post-hepatic jaundice causes
-Common bile duct obstruction (Stone, stricture, spasm or Cancer @ head of the pancreas)
Bilirubin: Interfering Factors
• Sample hemolysis
• Protect the blood sample from bright light
• Long list of drugs that can increase total bilirubin
Bilirubin: Interfering Factors
• Sample hemolysis
• Protect the blood sample from bright light
• Long list of drugs that can increase total bilirubin
Bilirubin: Normal Levels
• Total: 0.1-1.0 mg/dL
• Direct: 0-.2 mg/dL
• Indirect: 0.2-0.8 mg/dL
• Newborn total: 1-12 mg/dL
Bilirubin: Decision Levels
• 1.4 mg/dL
• 2.5 mg/dL: Jaundice
• 20 mg/dL – in baby – associated with kernicterous
Liver plays a major role in:
Liver Metabolism
Disease of the hepatobiliary system affects:
Plasma cholesterol
What serum proteins are synthesized in liver:
Albumin, fibrinogen and majority of globulins
Enzymes related to liver function
• Transaminases - ALT/AST
• Alkaline phosphatase
• LDH
• GGT
AMA are important for which disorder
Primary biliary cholangitis
ASMA are important for which disorder
Autoimmune hepatitis
Fetal liver produced:
Alpha fetoprotein (AFP)
AFP levels are _____ in adults
Very low
Increased AFP is useful in diagnosis of
Primary hepatocellular cancers
Acute Hepatitis: Types
-Viral (A-C)
-Viral: CMV, herpes simplex
-Bacterial
-Parasitic
How to differentiate between acute and chronic hepatitis based on duration
-Acute Hepatitis: <6 months
-Chronic Hepatitis: >6 months
Chronic Hepatitis: Types
-Hepatitis B &C
-Non-alcoholic steatohepatitis (NASH)
-Alcohol-related liver disease/alcoholic hepatitis
-Autoimmune liver disease
-Drug induced
Chronic Hepatitis can lead to increased risk of: (2)
-Cirrhosis
-Hepatocellular carcinoma
Acute Viral Hepatitis: Progression
- Incubation: No Symptoms
- Prodromal (Pre-icteric)
- Icteric
- Recovery: 2-4 weeks
Acute Viral Hepatitis: Prodromal (pre-icteric)
Main
• Anorexia
• Malaise
• Nausea/vomiting
Others
• RUQ pain
• New distaste for cigarettes
• Urticaria and arthralgia-Hep B
Acute Viral Hepatitis: Icteric
Hepatomegaly Persisits
Acute Viral Hepatitis: Lab Findings (Enzymes)
• Notable increases in ALT (5x) and AST (3x)
• Mild/moderate elevations in ALP, GGT, LDH
Acute Viral Hepatitis: Lab Findings (Bilirubin)
• Bilirubinuria
• Positive urine urobilinogen
• Hyperbilirubinemia (mixed)
Acute Viral Hepatitis: Lab Findings (CBC)
• Leukopenia with lymphocytosis
Hepatitis A (HAV): Epidemiology
Spread by fecal-oral route
Hepatitis A: Signs/Symptoms
• Young children may be asymptomatic
• Adults may have severe symptoms
Hepatitis A: Antibodies
HAV IgM antibody
• Appears 3-4 wks after exposure
• Peak 1 week later
• Normal at 2-3 months
HAV IgG
• Appears 2-4 weeks after IgM increase
• Peak 1-2 months later
• Slowly falls (detectable for >10 years)
Hepatitis A (HAV): Prognosis and Management
• Resolves spontaneously in most cases
• Lasts 6-12 weeks
• Treatment – supportive
Hepatitis B
Transmitted parenterally (needles) and through sexual intercourse
Hepatitis B: Signs/Symptoms
• Urticarial eruptions (Hives) and arthralgia (joint pain) possible
Hepatitis B: Serological Findings
1.HBsAg: 1st test to become abnormal
2. Anti-HBs (HBsAb): 2-6 weeks following diappearance of HBsAg
3. HBcAb: IgM and IgG tests available
.Acute HBV infection: Serological Findings
-HBsAg: Positive
-Anti-HBs: Negative
-IgM anti-HBc: Positive
-IgG anti-HBs: Negative
Chronic HBV infection: Serological Findings
-HBsAg: Positive
-Anti-HBs: Negative
-IgM anti-HBs: Negative
-IgG anti-HBc: Positive
Hepatitis C: Transmission
• Transmitted parenterally – blood and other bodily fluids
• Symptoms typical of viral hepatitis
Hepatitis C becomes chronic in ____ of cases
75%
Hepatitis C: Lab Findings
• Anti-HCV and HCV RNA do no differentiate between acute and chronic
Hepatitis C: Lab Findings
• Anti-HCV and HCV RNA do no differentiate between acute and chronic
First indication of chronic hepatitis
Abnormal aminotransferase levels
Chronic Hepatitis: Signs/Symptoms
-Many patients asymptomatic
-If undiscovered, first signs/symptoms may be those of cirrhosis
-Jaundice is rare
-Mild symptoms: Malaise, Anorexia, Fatigue, Low-grade fever, non-specific upper abdominal discomfort
Chronic Hepatitis: Signs/Symptoms
-Many patients asymptomatic
-If undiscovered, first signs/symptoms may be those of cirrhosis
-Jaundice is rare
-Mild symptoms: Malaise, Anorexia, Fatigue, Low-grade fever, non-specific upper abdominal discomfort
Chronic Hepatitis: Lab Findings
-Mild elevations of ALT and AST*
-ALP: Normal or elevated
-Bilirubin: normal until severe or advanced disease
Chronic Hepatitis: Serological Tests
-HBV and HCV
Chronic Hepatitis: Management & Treatment-Chronic HBV/HCV, Autoimmune, NASH, Alcoholic Hepatitis
-Chronic HBV/HCV: Antivirals
-Autoimmune: Corticosteroids
-NASH: Weight loss
-Alcoholic Hepatitis: Stop drinking immediately
NAFLD/NASH
-NAFLD: Accumulation of lipids in hepatocytes (asymptomatic)
-NASH: Accumulation of lipids in hepatocytes, leading to sustained inflammation and cell damage
Lipid accumulation is not associated with _______
Alcohol intake
NAFLD/NASH: Risk Factors
-Metabolic Syndrome
-Type 2 DM
-High triglycerides, low HDL
NAFLD/NASH: Lab Findings
-ALT/AST: May be only elevations
-Risk factors may be more indicative of disease than LFTs
NAFLD/NASH: Lab Findings
-ALT/AST: May be only elevations
-Risk factors may be more indicative of disease than LFTs
Differentiation of NAFLD/NASH requires:
Liver Biopsy
-NASH will have inflammation
Hepatic Steatosis: Lab Findings
-Notable GGT elevation
-Other liver enzymes can be normal or mildly elevated
Alcoholic Liver Disease/Alcoholic Hepatitis: S/Sx
-Fever, jaundice, fatigue
-RUQ pain, tender hepatomegaly
ALD/Alcoholic Hepatitis: Key Lab Findings
-WBCs increased
-Decreased serum albumin, increased serum globulin
-Increased prothrombin time
-Increased GGT (significant)
ALD/Alcoholic Hepatitis: Treatment
*Stop drinking alcohol
-Bed rest
Autoimmune Hepatitis: Symptoms
Acne, amenorrhea, arthralgia…
Autoimmune Hepatitis: Lab findings
Anti-smooth muscle antibodies (ASMA) often positive
Cirrhosis: Etiology
-Alcohol
-NASH
-Chronic Hepatitis
-Prolonged cholestasis
Cirrhosis: Signs/Symptoms
*Portal Hypertension: Ascities, esophageal variaces, hepatorenal syndrome, symptoms of heart failure
-Peripheral neuropathies (B12)
-Malabsorption Conditions
-Hormone Imbalalnces: Gynecomastia, hirsuitism
Cirrhosis: Key Exam Findings
Palpable, firm, smooth liver with blunt edge
Cirrhosis: Key Lab Findings
*Albumin significantly decreased
*Serum cholesterol decreased
*BUN decreased
*Uric Acid Decreased
-WBC normal
Cirrhosis: Definitive Diagnosis
Liver Biopsy
Primary Liver Cancer is usually a complication of:
Cirrhosis
Primary Liver Cancer: S/Sx
-Oftentimes asymptomatic
-Abdominal pain
-Weight loss
-RUQ mass
-Fever
-Jaundice (late)
Primary Liver Cancer: Lab Findings
*AFP (4x)-Warrants imaging
-Imaging: Ultrasound, MRI, contrast-enhanced CT
Metastatic Carcinoma of the Liver: Primary Sites
GI Tract, Breast, Lung, and pancreas
Metastatic Carcinoma of the Liver: S/Sx
-Hepatomegaly
-Non-specific cancer symptoms (weight loss, anorexia, fever)
Metastatic Carcinoma of the Liver: Lab Findings
-ALP, GGt, LDH tend to elevate
-ALT and AST findings are variable
-Bilirubin typically normal
Primary Biliary Cholangitis
-Inflammation and destruction of small bile dcuts within liver portal areas
PBC: S/Sx
Asymptomatic or may have symptoms of cholestasis (Pruritis, mild jaundice, steatorrhea)
PBC: Lab Findings (4)
-ALP and GGT increased
-Minimally increased AST and ALT
-Increase serum cholesterol
-AMA elevated
Cholestasis (Intrahepatic): Etiology
-Viral hepatitis, alcoholic liver disease, metastatic carcinoma, pregnancy, primary biliary cirrhosis, drugs
Cholestasis (Extrahepatic): Etiology
-Common bile duct stone, pancreatic carcinoma, stricture of CBD, Pancreatitis
Cholecystitis: Clinical Findings
-Colicky RUQ pain & tenderness
-Muscle guarding
-Pale Stool
-Intense pruritis
Cholecystitis: Clinical Findings
-Colicky RUQ pain & tenderness
-Muscle guarding
-Pale Stool
-Intense pruritis
Cholecystitis: Key Lab Findings
-High ALP/GGT (4x)
-High Serum Cholesterol: Acute (300-400)/Chronic (700-800)
-Total serum bilirubin moderately or considerable increased
-Leukocytosis with neutrophilia
Cholecystitis: Management
-Definitive Diagnosis: Abdominal ultrasound
-Vitamins A, D, E, K Supplementation
