T11-L8: Investigation of Liver and Pancreatic Disease Flashcards
What is the clinical presentation of late stage liver disease?
- Jaundice
- Gynecomastia - deranged oestrogen levels
- Spider navei
- Clubbing
- Bruising
- Pigmentation
- Itching
- Testicular atrophy
- Palmar erythema
- Ascites
- Oedema
- Encephalopathy
- Osteomalacia/osteoporosis
- Muscle wasting
- Varices
What measurements truly test liver function?
- Albumin Levels i.e. production of metabolites
- Prothrombin Time
- Bilirubin Levels i.e. clearances of endogenous substances
What tests are involved in routine LFTs to test for liver damage?
- Alkaline phosphatase (ALP)
- Transaminase - ALT (but also AST)
- Bilirubin
- Albumin
Also total protein and GGT (Glutamyl transferase)
Which aminotransferase is more is more specific to the liver?
ALT
What enzymes can we test that are produced by cells lining the bile cannaliculi and so makers of biliary tree damage?
Gamma-Glutamyl Transferase (γGT) - makers raised in structural damage
Alkaline Phosphatase - elevated due to increased production by cells lining the cannaliculi e.g. cholestasis, infiltrative disease, space occupying lesions and cirrhosis.
What can we suspect if there is no other abnormalities other than a raised ALP, including a normal ALP and no clinically obvious caused for a raised ALP?
ALP is also produced in the bone, kidneys, intestine and placenta. It may be aa disease outside the liver and so the next step is to check the calcium and bone profile.
In what cases can we see a raised GGT?
- Alcohol (most common)
- Enzyme inducing agents e.g. antiepileptic medications
- Fatty liver
- Heart disease
- Prostatic disease’s e
- Pancreatic disease
- Kidney disease
What is the difference in epidemiology in PSC and PBC?
Primary Biliary Cirrhosis - Strong female predilection
Primary Sclerosing Cholangitis - Men affected more than women
What is the difference in biochemical tests in PSC and PBC?
In Primary Biliary cirrhosis • There is often an incidental finding with an isolated raised ALP
• ↑IgM and specifically raised anti-mitochondrial antibodies (AMA)
In Primary Sclerosing Cholangitis:
• Progression over years from minor elevations of ALP to a very severe cholestatic condition with deep jaundice.
• Autoimmune and often related to IBD - particular UC
What disease show error in bilirubin metabolism?
- decreased activity of UDP glucuronyl transferase
• Gilbert’s, Crigler-Najjar - Reduced ability to excrete bilirubin glucuronide
• Dubin-Johnson, ROTOR
What is the common cause of elevated transaminases but normal ALP?
Hepatitis
What is the common cause of elevated ALP but normal transaminases?
Obstructive cause
What is the common cause isolated hyperbilirubinaemia?
Consider prehepatic causes e.g. increased reticulocytes or decreased haptoglobin
What are the causes of acute pancreatitis?
Hint: I GET SMASHED
I - idiopathic
G - Gallstones
A - Alcohol
T - Trauma
S - Steroids M - Malignancy/Mumps A - Autoimmune S - Scoprion Stings H - Hypercalcaemia/Hypertriglyceridemia E - ERCP D - Drugs
Why do we see hypocalcaemia in pancreatic disease?
Binding of calcium through fatty acids released through damage to the pancreas (saponification). Release of these and other pancreatic enzymes further increase and perpetuate the damage. This leads to a damage of inflammation, enzyme release, damage etc. This is especially seen in alcohol.
