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Midterm (AGPC 4) > Liver Function Tests > Flashcards

Liver Function Tests Flashcards

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1
Q

ALT / AST

A

shows injury to hepatocyte

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2
Q

Alkaline Phosphatase

A

shows injury to cholangiocytes- meaning obstruction to bile flow

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3
Q

Injury to hepatocyte (Hepatocellular)

A 
Viral hepatitis
Drugs affecting hepatocytes 
Alcohol liver disease 
Non-alcohol liver disease
Autoimmune hepatitis  
Hereditary diseases (hereditary hemochromatosis, Wilson disease)
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4
Q

Obstruction of bile flow

A

Gallstones in common bile duct
Pancreatic/ hepatic mass
Drugs affecting bile flow

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5
Q

ALT > AST

A

all hepatocellular conditions

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6
Q

AST > ALT

A

conditions caused by alcohol

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7
Q

AST > ALT (2:1) with AST in 100-200 u/L

A
  • Alcoholic liver disease

- Review alcohol hx

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8
Q

ALT > AST, with ALT in 1000 u/l

A
  • Acute viral hepatitis (A, B), acute drug induced injury, (acetaminophen >7.5 g/d)
  • Hepatitis A, B panel, acetaminophen level
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9
Q

ALT > AST, with ALT in 100s u/l

A
  • Chronic viral hepatitis (B, C), drug-related injury (TB medications, antiepileptic, methotrexate, statins, amiodarone, acetaminophen, amoxicillin-clavulanate), non-alcoholic fatty liver disease, congestive liver disease, autoimmune hepatitis
  • Hepatitis B, C panel, autoantibodies (ANA), review medication history (obesity, T2DM, hyperlipidemia)
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10
Q

Alkaline phosphatase (<120 u/L)

A

Marker of cholestatic injury (intrahepatic and extrahepatic)
Maybe slightly elevated in hepatocellular injury
Requires evaluation of biliary tree ( US-initial test, MRCP is more accurate

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11
Q

Elevated Alkaline Phosphatase - Ductal dilation on imaging - extrahepatic cholestasis

A
  1. Choledocholithiasis: sharp pain

2. Pancreatic Cancer: painless/dull pain

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12
Q

Elevated Alkaline Phosphatase - No Ductal dilation on imaging - intrahepatic cholestasis

A

metastatic disease (colon, prostate)- hepatocellular carcinoma

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13
Q

PT/INR (11-15 sec/1.0)

A

Most sensitive marker of synthetic function of the liver
Most sensitive marker of acute liver injury
Marker of prognosis
Increase in PT/INR= decrease in the synthetic liver capacity
**ACUTE CHANGES

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14
Q

Albumin (3.5-5.3 g/dl)

A

**NOT FOR ACUTE CHANGES
Marker of synthetic function of the liver
Decrease in albumin = decrease in the synthetic liver capacity
Albumin is not specific for the liver( decrease in albumin in nephrotic syndrome or malnutrition)
Maybe normal in acute injury

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15
Q

Total bilirubin (0.5 -1.0 mg/dL)

A

Marker of synthetic function

Indicator of severity of disease

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16
Q

Bilirubin >2mg/dl

A

Jaundice

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17
Q

Hepatitis A

A
  • Transmission: Fecal oral
  • At risk: Traveling to endemic areas (fecal contamination of water, food)
  • Only acute form; self-limiting. Fulminant hepatitis is rare
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18
Q

Hepatitis B

A
  • Transmitted by Blood, Unprotected sex, Mother-baby
  • At risk: Unprotected sex, IVD users
  • Acute and chronic. Chronic in 90% of infected infants and only 5% of infected adults.
    Cirrhosis (in 20% of chronically infected 20 years after exposure)
    Hepatocellular carcinoma (HCC 2% risk per year)
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19
Q

Hepatitis C

A
  • Transmitted: Blood, Unprotected sex (very rare)
  • At risk: IVD users, Healthcare workers
  • 85% of infected individuals will have chronic infection.
    Cirrhosis (in 20% of patients 20 years after exposure). Hepatocellular carcinoma (HCC 2% risk per year)
20
Q

Hepatitis D

A
  • Co-exist with B

- Same as B

21
Q

Hepatitis E

A

Transmission: Fecal-oral

- Same as A

22
Q

Clinical manifestation of Acute Hepatitis

A
  • Maybe completely asymptomatic
  • in severe cases:
    Fatigue
    Anorexia
    Weight loss
    Nausea, +/- vomiting
    Abdominal discomfort
    Low-grade fever
    (+/-) arthralgia
    Signs: Jaundice, scleral icterus, dark urine, pale stool, liver tenderness, hepatomegaly
23
Q

Clinical manifestations of chronic hepatitis

A

Asymptomatic (discovered by abnormal liver enzymes/ abnormal US imaging)
Or
Mild symptoms (fatigue, abdominal discomfort “ fullness”, anorexia)
Or
Symptoms of decompensated cirrhosis (ascites…)

24
Q

Signs and symptoms of decompensated liver cirrhosis: Hepatic Insufficiency

A 
coma
jaundice
spider nevi
pectoral alopecia
gynecomastia
liver damage
palmar erythema
altered hair distribution
testicular atrophy
hemorrhagic tendency
ankle edema
25
Q

Signs and symptoms of decompensated liver cirrhosis: portal hypertension

A 
esophageal varices
splenomegaly
distension of abdominal veins
ascites
bone marrow changes
extremity muscle wasting
hemorrhoids
26
Q

Ascites: physical examination

A

bulging flanks, fluid wave, shifting dullness

27
Q

Workup for suspected hepatitis

A

Consider travel history, risk factors, alcohol consumption, medications review, history of diabetes, obesity, hyperlipidemia

LFTs and bilirubin (increased direct bilirubin, increased ALT more than AST, minor elevation of Alk phosphatase)

Viral hepatitis serology (A,B,C)

Consider CMV serology (CMV IgM), EB (EB IgM)

28
Q

(+) IgM means

A

active disease

29
Q

Hepatitis A serology

A

Patient 1: (+) anti-HAV IgM, (+) anti-HAV IgG = active

Patient 2: (+) anti-HAV IgM, (-) anti-HAV IgG = early active

Patient 3: (-) anti-HAV IgM, (+) anti-HAV IgG = immune due to vaccine or hep A resolved

30
Q

Hep B antigens and antibodies

A
  • HBs Ag: indicates ACTIVE INFECTION
  • Anti HBs: resolution of active infection and immunity & successful vaccination
  • HBc Ag: NOT detected in blood
  • IgM Anti HBc: ACUTE INFECTION
  • IgG Anti HBc: RESOLUTION OF INFECTION
  • HBe Ag: high level of infectivity
  • Anti HBe: low level of infectivity
31
Q

Acute Hep B

A

HBs Ag, IgM anti HBc

32
Q

Resolution of Acute Hep B

A

anti HBs, IgG anti HBc

33
Q

Chronic Hep B

A

HBs Ag, IgG anti HBC

34
Q

Hep C Serology

A

Patient 1: (-) anti-HCV = no disease

Patient 2: (+) anti-HCV , followed by (+) HCV RNA = active disease

Patient 3: (+) anti-HCV , followed by (-) HCV RNA = resolved/ treated

35
Q

Treatment of acute viral hepatitis (A and B)

A
  • Supportive (anti-emetics, adequate hydration, adequate nutrition)
  • AVOID alcohol
  • Steroids, high-carbohydrate and low-protein diets ARE NOT recommended
36
Q

Treatment of chronic hepatitis B

A

Oral direct antiviral therapy monotherapy, 20-25% achieve suppression of viral load

Only patients with significant viral activity (HBeAg and high viral load should be treated

Goal is suppression Hep B replication (low viral load -HBV DNA) and HBeAg seroconversion

Long-term therapy is necessary (4-5 years and more)

37
Q

Treatment of chronic hepatitis C

A

Oral direct antiviral therapy (one pill once a day), >90% patients achieve cure

Goal is to achieve undetectable HCV RNA for at least 6 months after cessation of therapy (= cure)

The treatment and the duration is based on Hepatitis C genotype (genotype 1 accounts for 70%), usually 12-24 weeks

All patients with active HCV infection would benefit, with the exception of those with life expectancy less than 12 months

38
Q

Treatment of compensated cirrhosis

A

Surveillance of HCC every 6-12 months (ultrasound)

Screening for esophageal varices (endoscopy)

Avoidance alcohol (no safe level !)

HAV, HBV, pneumococcal pneumonia, and influenza immunizations

Statins can be safely used

Acetaminophen may be used in persons with cirrhosis in doses of up to 2 g daily

Aspirin and other NSAIDs should be avoided

High-caloric small meals

39
Q

Treatment of decompensated cirrhosis

A

Esophageal varices – non-selective beta-blockers ( decrease portal flow)

Ascites – diuretics (Spironolactone) and sodium restriction diet

Hepatic encephalopathy- lactulose (decrease absorption of ammonia)

40
Q

Screening for Hep C

A
  • born 1945-1965 regardless of risk
  • IV drug users
  • HD pt
  • HIV pt
  • MSM
  • Abnormal liver enzymes
41
Q

Screening Hep B

A
  • all pregnant women
  • IV drug users
  • HIV
  • MSM
  • abnormal liver enzymes
42
Q

Hep A Vaccine (2 doses)

A
  • travelers to endemic areas
  • MSM
  • drug users (poor housing conditions, high hep c prevalence)
  • pt with chronic liver disease
43
Q

Hep B vaccine (3 doses)

A
  • IVD users
  • multiple sex partner
    • MSM
  • Healthcare/ public safety workers
  • Patients with chronic liver conditions
  • Patients on HD
  • Patients with DM 19-59 y. (sharing needles, finger stick devices, syringes , needles)
44
Q

Post-exposure Hep A

A
  • for close household and sexual contact during outbreak
    For healthy adults <40y/o&raquo_space; Hepatitis A vaccine (x 2 doses)
    For > 40y/o&raquo_space; HAIG followed by vaccination
45
Q

Post-exposure Hep B

A
  • percutaneous exposure, sexual contact

HBIG and Hepatitis B vaccine (x 3 doses)

Midterm (AGPC 4) (6 decks)

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