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Kat's Pathology > Liver Function Tests and Cases > Flashcards

Liver Function Tests and Cases Flashcards

1
Q

What vessel drains blood from the liver

A

Hepatic vein

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2
Q

What vessels supply blood to the liver (2)

A

Hepatic artery

Portal artery

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3
Q

What are the basic functions of the liver (6)

A 
Intermediary metabolism 
Protein synthesis 
Xenobiotic metabolism 
Hormone metabolism 
Bile synthesis 
Reticul-endothelial function
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4
Q

What is involved in the intermediary metabolism (6)

A 
Glycolysis 
Glycogen storage
Glucose synthesis 
Amino-acid synthesis 
Fatty acid synthesis 
Lipoprotein metabolism
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5
Q

What is intermediary metabolism

A

Enzyme-catalysed processes within cells that extract energy from nutrient molecules and use that energy to construct cellular components

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6
Q

Approximately how many proteins does the liver produce

A

Approximately 1200 plasma proteins - including clotting factors and albumin

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7
Q

What are three key steps of metabolism carried out in the liver

A

Chemical modification
Conjugation
Excretion

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8
Q

What chemical modifications take place in the liver (3)

A

P450 enzyme system
Acetylation/de-acetylation
Oxidation/reduction

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9
Q

What are some key conjugations that occur in the liver (2)

A

Glucuronate

Sulphate

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10
Q

What three classes of hormones does the liver synthesis (3)

A 
Vitamin D (hydroxylation)
Steroid hormone (conjugation, excretion) 
Peptide hormone (catabolism)
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11
Q

What is the parent hormone from which all steroids are derived

A

Cholesterol

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12
Q

What are the functions of bile (3)

A

Excretion
Micelle formation
Digestion

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13
Q

What are the constituents of bile (7)

A 
Water
Bile salts/acids
Bilirubin 
Phospholipids 
Cholesterol 
Proteins 
Drugs and Metabolites
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14
Q

What protein transports bilirubin from phagocytes to hepatocytes

A

Albumin

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15
Q

What do hepatocytes do to bile

A

Convert it from free bilirubin to cnojugated bilirubin

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16
Q

What do the Kupffer cells of the liver do (3)

A

Clearance of infection and LPS
Antigen presentation
Immune modulation (cytokines, etc…)

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17
Q

What are the retoculoendothelial functions of the liver (2)

A

Kupffer cell function

Erythropoesis

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18
Q

What is included in LFTs (8)

A 
Alanine transaminase ALT
Aspartate transaminase AST
Alkaline phosphate ALP
Albumin
Bilirubin 
Gamma glutamyl transferase GGT
Clotting factors PT
Alpha feteproteins AFT
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19
Q

What are serum markers of liver cell damage (4)

A

ALT
AST
ALP
GGT

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20
Q

What is a live tumour marker

A

AFP

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21
Q

What are serum markers of liver function (3)

A

Albumin
Pro-thrombin time PT
Bilirubin

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22
Q

What measures the synthetic function of the liver (2)

A

Albumin

PT

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23
Q

What constitutes the portal triad

A

Bile duct
Portal arteriole
Portal venule

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24
Q

What cells are present in the sinusoids

A

Kupffer cells

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25
Q

Where are ALT and AST present

A

Within cytoplasm of hepatocytes

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26
Q

What causes a raised ALT and AST

A

Hepatocyte death

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27
Q

What other organs are ALT and AST present in, in lower amounts (4)

A

Muscle
Kidney
Brain
Pancreas

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28
Q

What LFT rises more in alcohol related damage

A

AST

29
Q

What is raised in cirrhosis

A

AST/ALT ratio

30
Q

Where is GGT found (7)

A 
Liver
Kidney
Pancreas
Spleen
Heart
Brain
Seminal vesicles
31
Q

Where in the liver is GGT found (2)

A

Hepatocytes

Epithelium of small bile ducts

32
Q

What causes an elevated GGT (3)

A

Chronic alcohol use
Bile duct disease
hepatic metastasis

33
Q

Where is ALP found (2)

A

Liver isoenzyme found in sinusoidal and canalicular membranes

34
Q

What causes a marked rise in ALP (2)

A

Obstructive jaundice

Bile duct damage

35
Q

What causes a moderate rise in ALP (2)

A

Viral hepatitis

Alcoholic liver disease (i.e. hepatocyte damage)

36
Q

What are some other sources of ALP (5)

A 
Bone 
Small intestine 
Kidney 
WBCs
Placenta
37
Q

What non-liver causes can cause a rise in ALP

A

Bone disease (especially metastatic and pregnancy)

38
Q

What is albumin

A

The major protein synthesised by the liver (8-14g/day)

39
Q

What is the molecular mass of albumin

A

65,000

40
Q

What is the half life of albumin

A

20 days

41
Q

What is the role of albumin (2)

A

Contributes to oncotic pressure

Binds steroids/drugs/bilirubin/calcium

42
Q

What causes low albumin levels (3)

A

Low production (chronic liver disease, malnutrition)
Loss (e.g. gut, kidney)
Sepsis (3rd spacing)

43
Q

What is PT a good measure of liver function

A

Half life of hours

Acute marker of liver function/damage

44
Q

What is AFP

A

Alpha-feto protein

Glycoprotein with a molecular weight of 69,000/albumin superfamily

45
Q

What are the normal levels of AFP in adulthood

A

Low concentrations/no known function

46
Q

What is AFP used for (5)

A

Used in diagnosis of hepatocellular carcinoma (but may rise too late, or not at all)
Also raised in hepatic damage/regeneration
Raised in pregnancy
Raised in testicular cancer

47
Q

What does raised bilirumin cause

A

Jaundice

48
Q

What bilirubin is raised with pre-hepatic haemolysis

A

Unconjugated bilirubin

49
Q

What bilirubin is raised in hepatic disorders

A

Both unconjugated and conjugated

50
Q

What bilirubin is raised in post-hepatic disorders

A

Conjugated bilirubin

51
Q

Where does conjugated bilirubin appear

A

Urine

52
Q

Jaundice
Raised bilirubin
Normal enzymes (2)

A

Haemolysis

Gilbert’s disease

53
Q

Jaundice
Raised ALP
Dilated bile ducts

A

Obstruction (gallstones, cancer)

54
Q

Jaundice
Raised ALP
Undilated bile ducts (3)

A

Drugs
Primary biliary cirrhosis/primary sclerosing cholangitis
Pergnancy

55
Q

Jaundice

Raised ALT/AST

A

Acute or chronic hepatocellular damage

56
Q

Should bilirubin be detected in the urine

A

No! Large amounts can be detected with the naked eye though (dark urine)

57
Q

Is urobilinogen detected in urine

A

Normally detected in small amounts in the urine

58
Q

What causes an increase in urine urobilinogen (3)

A

Haemolysis
Hepatitis
Sepsis

59
Q

What causes absence of urobilinogen

A

Obstructive jaundice

60
Q

What clinical syndrome is associated with pale stools and dark urine

A

Obstructive jaundice

61
Q

Beyond LFTs, what other blood tests can be used to determine the cause of liver pathology (10)

A 
Viral serology 
Auto-antibodies
Iron studies 
Copper studies
Detailed drug history 
Radiological imaging - US and CT
Fibroscan 
Histopathology 
ERCP
62
Q

What other tests can be used to determine liver function (3)

A

Dye tests - indocyanine green/bromsulphalein (measure excretory capacity of liver, measure hepatic blood flow)
Breath tests - aminopyrien/galactose (carbon 14) - measure residual functioning liver cell mass.
Serum bile acids - elevated, especially in cholestasis (10-100s in cholestasis of pregnancy, 25x in PBC/PSC)

63
Q

24 year old male medical student
noticed that his sclera went yellow after an end of term party, has noticed this a few times
fit, no PMH
SH single binge drinker, denies other drugs
not on any medication
no abnormalities on examination
no bilirubinuria on dipstick testing

bil 36 umol/L (<17)
alb 40 g/L (35-51)
ALT	35 IU/L (<40)
AST	36 U/L (<40)
alk phos 86 U/L (30-130)
GGT 35 U/L (11-42)

Elevated conjugated bilirubin in fasting bilirubin test.

A

Gilberts.

64
Q

38 year old female secretary presented with itch and jaundice, dark urine
PMH removal of a benign breast lump
UTI 5/7 earlier treated by GP
SH single, 21 units of alcohol/week, smokes 15/day
O/E no signs of chronic liver disease
bilirubinuria seen on dipstick of urine

bil 236 umol/L (<17)
alb  38 g/L (35-51)
ALT	65 IU/L (<40)
AST	55 U/L (<40)
alk phos 1024	U/L (35-51)
GGT 59 U/L (11-42)

US - no bile duct obstruction

A

Drug induced cholestasis (intrahepatic, secondary to augmentin)

The jaundice should resolve over the next 3 weeks.

65
Q

74 year old retired publican
3 week history of itch, pale stools, dark urine, yellow sclera
2 month history of weight loss-12 kg’s
PMH cardiomyopathy, peripheral neuropathy,
O/E jaundiced, no signs of chronic liver disease but epigastric fullness noted
bilirubinuria noted on urine dipstick
O/E: Courvoisier’s sign (in the presence of a painless palpable gallbladder, jaundice is unlikely to be caused by gallstones)

bil 120 umol/L (<17)
alb 29 g/L (35-51)
ALT 36 IU/L (<40)
AST 45 U/L (<40)
alk phos 450 U/L (35-51)
GGT 98 U/L (11-42)

US - dilated common bile duct and possible pancreatic mass.

A

Pancreatic adenocarcinoma

CT scan and biopsy confirmed this plus local spread.

Liver looked cirrhotic.
A palliative stent was placed in the CBD
Jaundice and itch resolves, but he passed away 3 months later

66
Q

18 year old female jaundiced art student
returned from trip to Goa 1 week previously
felt terrible for the last 10 days, fevers, diarrhoea, joint pain, last 2 days had turned yellow
admitted to taking “some tablets” in a nightclub + had small tattoo done
no PMH, anti-malarial tablets only
O/E jaundiced, no signs of chronic liver disease or IVDU

bil 168 umol/L (<17)
alb 38g/L (35-51)
ALT	2500 IU/L (<40)
AST	2380 U/L (<40)
alk phos 190 U/L (35-51)
GGT 39 U/L (11-42)

US - no bile duct dilation, but swollen liver

A

Acute hepatitis A

Jaundice resolves and made a full recovery

67
Q 
a 54 year old lawyer 
noted by GP to have abnormal liver function tests
PMH hernia repair
meds nil
alcohol 2 units/ day
denied ever taking any drugs
O/E palmar erythema and 5 spider naevei
bil 29 umol/L (<17)
alb  27 g/L (35-51)
ALT	49 IU/L (<40)
AST	46 U/L (<40)
alk phos 55 U/L (35-51)
GGT 62 U/L (11-42)
INR 	1.3

US - coarse liver texture and large spleen
HepC serology confirmed
Admitted to using heroin once in the 70s.
Liver biopsy confirmed cirrhosis.

A

Chronic Hepatitis C infection

68
Q 
19 year old student 
split up with boyfriend / exams
taken 32 g paracetomol / Alcohol++
PMH nil / no previous psychiatric Hx
meds nil
denied ever taking any drugs
O/E alert / vomiting / resps. 28
bil 25 umol/L (<17)
alb 40 g/L (35-51)
ALT	550	IU/L (<40)
AST	3400 U/L (<40)
alk phos 200	U/L (35-51)
GGT 450	U/L (11-42)
INR	2.8
ABG Ph 7.2  BE -13
A

Paracetamol overdose.

Treated with n-actyl cysteine
Transfered to transplant centre, received a transplant 3 days later - survived

Kat's Pathology (105 decks)

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