Liver Disease Flashcards
List the common liver function tests
Aspartate Aminotransferase (AST, SGOT) Alanine Aminotransferase (ALT, SGPT) Alkaline Phosphatase (ALP) Total Bilirubin Albumin *not on LFT panel but still used: Gamma Glutamyl Transpeptidase PT
Where is aspartate aminotransferase (AST) enzyme made?
RBC's Liver Heart Muscle tissue Pancreas Kidney
Normal values of AST are
Low
Abnormal Values of AST are
high
What does an increased AST indicate?
damage to tissue (not very specific)
Amount of AST in blood is directly related to extent of tissue damage (time = tissue)
What test can AST be done along with to determine whether the liver or another organ has been damaged?
ALT
Where is alanine aminotransferase (ALT) enzyme made?
Mainly in the liver, but also in small amounts in kidneys, heart, muscles pancreas
Normal values of ALT are?
Low
Abnormal values of ALT are?
High
What can elevated ALT levels indicate?
liver disease (more convincing when associated with elevated AST)
Where is Alkaline Phosphatase (ALP) enzyme made?
Liver Bone intestines kidneys placenta of preg
What body part makes the most ALP?
liver (more than other organs/bones)
What conditions can cause elevated ALP?
rapid bone growth (during puberty) bone disease hyperparathyroidism vit D deficiency Damaged liver cells
What is the function of gamma glutamyl transpeptidase in the body?
transport molecule that helps liver metabolize drugs/toxins
Where is glutamyl transpeptidase found in the body?
concentrated in the liver Also found in GB Spleen pancreas kidney NOT IN THE BONES
What other lab test is helpful to use along with GGT to diagnose liver disease?
ALP
Not found in bones, so helps r/o bones as cause of elevated lab.
What does a total bilirubin measure?
amount of bilirubin in the blood
What is bilirubin a by-product of?
RBC’s are broken down daily-bilirubin is produced as a result. The liver then breaks down the bilirubin and it is excreted in the feces.
What 2 forms of bilirubin exist?
direct (conjugated) bilirubin
indirect (unconjugated) bilirubin
Elevated levels of indirect (unconjugated) bilirubin are a sign of____?
hemolysis or failure of liver uptake
Elevated levels of direct (conjugated) bilirubin are a sing of ___?
Impaired secretion of liver
Which of the 2 forms of bilirubin is measured directly in the blood?
direct (conjugated)
Where is Albumin produced?
liver
What is the fxn. of albumin?
moves bilirubin calcium hormones medications through the blood Keeps fluid in the blood from leaking into capillaries
What is albumin used to test for?
kidney and liver dz
greatly decreased values of Albumin are indicative of?
Liver/kidney dz
decreased values of albumin are indicative of?
Absorption problem post surgery malnutrition low protein diet crohns etc.
Increased levels of albumin are indicative of?
dehydration and high protein diet
What will occur to Prothrombin time in the setting of chronic liver dz?
increase
Define Steatosis
fatty infiltration of the liver
Define steatohepatitis
fatty infiltrate PLUS inflammation
Define cirrhosis
Chronic degenerative dz in which cells are damaged and replaced by scar tissue
functions of the liver
Conjugates bilirubin produces bile produces many proteins processes ETOH, some meds/toxins Regulates lipids Converts glycogen into glucose and vice versa Excretes some wastes storage unit
Definition of Alcoholic liver dz?
Acute or chronic inflammation and parenchymal necrosis of the liver induced by ETOH
Which of the discussed liver diseases is reversible?
Alcoholic liver dz
Non alchoholic fatty liver disease
Which type of liver dz is the most common precursor of cirrhosis in the US?
Alchoholic liver dz
What are the three pathologic stages of alcoholic liver dz?
Fatty liver-reversible
Alcoholic hepatitis-reversible
Cirrhosis-irreversible
Fatty liver =
steatosis
asymptomatic
Alcoholic hepatitis =
Steatohepatitis
Asymptomatic-symptomatic
_______ as the first histological response in response to any hepatotoxic stimuli (ETOH in ALD)
fat accumulation (steatosis)
What is the deficiency found in ALD in the liver?
alcohol dehydrogenase deficiency
What is the hallmark of the shift from steatosis to steatohepatitis in ALD?
Hepatocyte injury
RF for ALD?
Alcohol intake (duhhhhh) Females more than males Concurrent viral Hep C Genetics Fattly liver/obesity
ETOH threshold for females for developing liver dz?
Chronic use exceeding 30-40g/day (3/4 beers a day)
ETOH threshold for males for developing liver dz?
Chronic use exceeding 80g/day (6/7 beers a day)
sx of early (fatty liver) ALD?
Asymptomatic Hepatomegally RUQ tenderness occasionally Nausea Jaundice - very rare
sx of advanced steatohepatitis in ALD?
Asymptomatic in some Fever SPIDER NEVI jaundice abd tenderness/acute and. encephalopathy portal hypertension (ascites, esophageal varicies)
Lab finding for ALD early?
Modest increase in GGTP, AST, ALT
Hypertriglyceridemia
hypercholesterolemia
hyperbilirubinemia
Lab finding for ALD advanced?
SEVERE INCREASE in GGTP, AST, ALT, (AST greater than ALT (ratio greater than 1)) Hyperbilirubinemia ALK PHOS HIGH** HYPOALBUMINEMIA** INCREASED PT**
Imaging for ALD?
US detects fatty infiltration
T/F US can distinguish between fibrosis and inflammation in ALD?
FALSE
What test is used as gold standard for ALD to confirm diagnosis and guide therapy?
Liver Bx
How can you differentiate ALD from NASH?
Not on Bx (can’t tell difference).
Have to get a good HX from pt.
General tx for ALD?
Abstain from ETOH
Nutrition (particularly in malnourished/anorexic pt’s)
Psych.
Pharm Tx for ALD?
Methylprednisolone reduces short term mortality
Pentoxyfylline (for severe)
Most important prognosis for pt’s with ALD?
continued ETOH use
What is the MC chronic liver dz in the US?
Nonalchoholic fatty liver disease (NAFLD)
Why is there an increase in the US in NAFLD?
rise in childhood obesity
MC causes of NAFLD?
Obesity (MC) DM Hypertriglyceridemia Meds (steroids) Cushings syndrome/hypothyroidism PCOS OSA Metabolic syndrome
RF for progressive NAFLD?
Older age
obesity
DM
SX of NAFLD?
Mostly asymptomatic
RIQ discomfort
Hepatomegaly (75% of pt’s)
Progression of chronic liver dz is common
Labs for NAFLD?
may be normal or mildly elevated AST/ALT alk pos.
Ratio of AST:ALT is almost always greater than 1
Imaging for NAFLD?
may be seen on CT, US MRI but won’t distinguish between stages
Diagnostic test of choice for NAFLD?
Liver Bx
lifestyle tx for NAFLD
Wt loss
dietary fat restriction
exercise
Pharm options that are being studied for use in NAFLD?
TZD’s
Vit. E
Metformin (but causes wt gain)
Pentoxyfylline
Surgical options for NAFLD?
Gastric bypass
What percentage of pt’s with NAFLD progress to NASH?
25%
define NASH?
Nonalcoholic steatohepatitis
NASH histologically presents exactly like ____?
Alcoholic hepatitis
What distinguishes NASH from ALD?
lack of Hx of chronic excessive ETOH use
Common sx of NASH?
fatigue
wt loss
weakness
What confirms diagnosis of NASH?
Liver bx
What are the 2 most common causes of Cirrhosis in the US?
Alcohol and Hep C are 2 MC causes of Cirrhosis in the US
Describe three stages of Cirrhosis?
Compensated-no complications
Compensated with varices
Decompensated-with complications
Complications of Cirrhosis
Portal hypertension (ascites, spontaneous bacterial perionitis, variceal bleeding) Hepatorenal syndrome hepatic encephalopathy Hepatopulmonary HTN malnutrition coagulopathy bone dz Hematologic abnormalities
sx of cirrhosis
weakness fatigue anorexia wt loss stigmata of liver dz (see complications)
Standout symptoms of cirrhosis?
Gynecomastia Caput medusa (dilated abd vessels) Asterixis (dorsiflexion of palms) spider angiomas (trunk/upper arms) Dupuytren's contracture (can't straighten finger) Palmar erythema (spares palmar region) ascites esophageal varices
Labs that are abnormal in cirrhosis?
(can be normal/abnormal depended on stage) macrocytic anemia WBC low or high (if infxn.) thrombocytopenia prolonged PT Elevated AST/ALT and ALP Bili elevated Albumin decreased GGTP increased Serum sodium decreased Vit D level low
Gold standard for diagnosis of cirrhosis?
Liver BX
When is a liver Bx not needed?
if clinical, lab, and radiologic data strongly suggests cirrhosis already
Imaging for Cirrhosis?
Doppler US (liver size, nodules, ascites, patency)
CT/MRI
EGD
General Tx for cirrhosis?
Tx cause (ETOH, Hep C, Hep B)
proper diet
psych counseling
vaccine UTD
Tx for cirrhosis (meds)
NONE!
What is TX aimed at for Cirrhosis?
Complications
Prevention of progression
What is the MC complication of cirrhosis?
Ascites and edema
tx for ascites?
restrict Na consumption
diuresis (spironolactone first, add loop)
Paracentesis
TIPS
Tx of Variceal hemorrhage
Vasoconstricting agents
Balloon tamponade
TIPS/band ligation
Prophylaxis-routine screening for all pt’s with cirrhosis
define hepatorenal syndrome?
Development of renal failure in pt’s with advanced liver dz.
Progressive increase in _____ occurs during hepatorenal syndrome?
Creatinine
Why does hepatic encephalopathy occur?
buildup of toxins in the body , neurotoxins are not removed by live and end up in the brain.
Sx of hepatic encephalopathy?
mental status change hypersomnia personality change asterixis brain swelling high emonia
tx of hepatic encephalopathy?
Hydration with IV fluid
electrolyte correction
Lactulose (removes GI nitrogenous product)
Mannitol (decreases brain swelling)
Rifaxim or metronidazole plus neomycin If pt doesn’t tolerate lactulose
zinc supplementation
Signs of hepatopulmonary syndrome with cirrhosis?
dyspnea and drop in O2 sat that is worse when UPRIGHT. (weird)
define portopulmonary HTN
presence of pulm htn. in pt’s with portal htn.
how is portopulmonary HTN diagnosed?
echo and cardiac cath.
Tx of malnutrition 2nd to cirrhosis?
sietary supplementation
How common in coagulopathy in cirrhosis?
VERY- universal in all pt’s with cirrhosis
tx of coagulopathy in Cirrhosis?
Vit K (if Vit K is diminished)
If synthesis of clotting factors d/t mass in liver
Vit K will NOT correct problem. Tx requires FFP if active bleeding or before surgery
Tx for bone disease 2nd to cirrhosis?
Bisphosphonates
What is the ultimate tx of decompensated cirrhosis?
Liver transplant
Define hemochromatosis
inherited disorder of iron metabolism.
results in progressive increase in iron deposition which can cause cirrhosis
What labs can be used to evaluate for Hemochromatosis?
Elevated fasting transferrin sat and elevated ferritin level
genetic testing, liver bx
Tx of hemochromatosis?
regular phlebotomy
Define Wilson’s disease?
Autosomal recessive d/o of copper homeostasis w/ failure to excrete excess copper leading to liver damage
What groups are generally affected by Wilson’s disease?
young adults and adolescents
What group is usually effected by Wilson’s disease?
young adults and adolescents.
Important PE finding of Wilson’s disease?
Kayser-Fleisher corneal rings (ring of copper around the eye).
How is Wilson’s disease diagnosed?
Low serum ceruloplasmin concentration and increased hepatic copper on LIVER BX.
Tx of Wilson’s disease?
Copper-chelating agents indefinitely (penicillamine)
define alpha-1 antitrypsin deficiency
autosomal recessive d/o that causes abnormal folding of the alpha 1 antitrypsin protein leading to failure of the liver (also effects pulm system-emphysema)
Diagnosis of Alpha-1 antitrypsin is done by doing___?
phenotype testing and alpha 1 antitrypsin levels
tx of alpha-1 antitrypsin deficiency?
Liver transplant is curative.
