Liver Labs CIS (Brozna)

Question 1

labs that say whether liver function is still ok?

Answer 1

PT

albumin

Question 2

diseases to think about with high alk phos, not such high liver enzymes?

Answer 2

obstructive (stones) or primary sclerosing cholangitis

Question 3

what to think about with high bilirubin

Answer 3

bilirubin pretty much only goes up with complete obstruction OR loss of a lot of hepatocytes (chronic process)

Question 4

Isolated markedly elevated AST in the setting of normal liver test including ALT suggest

Answer 4

unlikely to be due to liver disease. Look to another organ system that is injured and could release AST. Most likely muscle necrosis check with creatinine kinase

Question 5

High AST/ALT suggests

Answer 5

alcohol as a cause. With low albumin, this picture would be typical of severe alcoholic hepatitis, usually with cirrhosis.

Question 6

very high AST and ALT, high PT, super high bilirubin

Answer 6

Hepatocellular process with marked necrosis of hepatocytes. Elevated PT but normal albumin suggests acute disease. Increased PT suggests acute/fulminant liver failure. This would be typical of a very severe acute viral hepatitis, severe toxicity due to drugs such as acetaminophen or severe ischemic injury to much of the liver.

Question 7

how can we tell if alk phos is from the liver or not?

Answer 7

do the GGT (gamma glutamyl transferase). If it’s up, then the alk phos is probably from the liver. If not, could be coming from somewhere else.

Question 8

low albumin with AST and ALT that are only slightly high

Answer 8

suggests chronic decompensated cirrhosis

Question 9

Hi alk phos but bilirubin not elevated

Answer 9

Cholestatic liver disease

. This often occurs with:
Partial obstruction of the bile ducts allows sufficient bile to pass to the intestine to eliminate bilirubin.
Complete obstruction of some of the bile ducts in the liver but not all the ducts. The rest of the liver (not obstructed portion) usually has sufficient reserve to fully eliminate the daily load of bilirubin.

Question 10

transaminitis

Answer 10

elevated AST and ALT

Differential Diagnosis of Mild Transaminitis
Ingestion: Alcohol and Medications
Infection: Hep B and C
Immune: Autoimmune Hepatitis
Inherited: Wilson’s Dz, Hemochromatosis
BMI : Hepatic Steatosis

Question 11

The Differential Diagnosis of AST & ALT >1000

crucial tests

Answer 11

Alcohol,maybe, but if AST/ ALT pretty high… still need to consider alcohol but rule out other common causes of very high AST, ALT
Ischemic Hepatitis
Acute Viral Hepatitis (Hep A, Hep E)
Tylenol Toxicity

What are the three crucial tests?
Tylenol Level
Creatinine and INR (to calculate MELD Score)

Question 12

Why is Tylenol level needed NOW?

Answer 12

To guide the emergent use of N-Acetyl-Cystine

To make a diagnosis

Question 13

Why is creatinine and INR needed NOW?

Answer 13

With Bili and Albumin, it is used to calculate a MELD score in fulminant hepatic failure
(0.957 * ln(Serum Cr) + 0.378 * ln(Serum Bilirubin) + 1.120 * ln(INR) + 0.643 ) * 10
The MELD score will define 90-day mortality and stratify need for liver transplant evaluation

Question 14

Summary of Elevated Transaminase Differential Diagnoses- extrahepatic causes

Answer 14

Celiac Disease (may be occult)
Thyroid Disease
Adrenal Insufficiency
Myocardial Infarction
AST was “the troponin” of the 1950’s and 60’s
Muscle disorders or inborn metabolism defects
Strenuous exercise

Question 15

Slight elevation of transaminases
Moderately elevated Alk Phos (>50% ULN)
Synthetic function grossly intact
Borderline elevation in bilirubin?
Predominant Pattern: Moderate cholestasis borderline bilirubin

What test should be ordered next?

Answer 15

GGT
if up- biliary tree

if down- placenta, intestine, bone

Question 16

In a pregnant patient with mild cholestasis, and positive GGT, consider …

and if negateve GGT, consider

Answer 16

cholestasis of pregnancy, which may present as a pruritic rash as in this case

if negative,
consider physiological rise in alk phos from the placenta (up to 50% increase from ULN)

Question 17

21-year old man, sinusitis, amoxicillin, comes back with

Pure unconjugated hyperbilirubinemia without cholestasis

Answer 17

the differential diagnosis is PCN induced hemolytic anemia vs. Gilbert Syndrome

On physical exam, pallor and splenomegaly may support hemolytic anemia

Gilbert is a diagnosis of exclusion, so the next tests must exclude hemolytic anemia:
CBC with manual smear
Haptoglobin
LDH
Warm Agglutinins

Question 18

What if this patient had a pure conjugated hyperbilirubinemia?

Answer 18

Consider Dubin-Johnson Syndrome or Rotor Syndrome
(These diseases rarely present in adults)
Carefully review medications that might cause decreased bile excretion
With a normal Alk Phos, likely intrahepatic cholestasis