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Pancreatic and biliary disease. Intrahepatic cholestasis of pregnancy. Presents with sometimes intense pruritis Functional disorder of bile secretion ALP mod high, Bili high, Transaminases <200, NORMAL FUNCTIONAL TESTS, NORMAL PLTS, NORMAL COAGS

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intrahepatic cholestasis of pregnancy
Intrahepaticcholestasis of pregnancy
  • Presents with sometimes intense pruritis
  • Functional disorder of bile secretion
  • ALP mod high, Bili high, Transaminases <200, NORMAL FUNCTIONAL TESTS, NORMAL PLTS, NORMAL COAGS
  • Watch for fat malabsorbtion, vitamin deficiencies (decreased bile salts)
acute pancreatitis
Acute Pancreatitis
  • Causes:
    • EtOH and Gallstones
      • 75% of people with negative RUQ u/s have sludge or micoliths
    • Drugs: Lasix, thiazides, estrogen, azathioprine, tetracycline, sulfa drugs, ddI, ddC, valproic acid, 6-MP, L-asparginase
    • Hypertriglyceridemia >1000mg/dl
    • Cystic fibrosis
    • Hypercalcemia
    • Trauma
    • ERCP
slide4

Physical exam signs and symptoms:

  • Pain radiating from epigastrium “boring through” to the back
  • Cullen’s sign
    • blue around the umbilicus
  • Turner’s Sign
    • purple or green discoloration of the flanks.

Acute Pancreatitis (continued)

slide5

Dx:

    • Elevated amylase and lipase, when amy >900 U/L and lipase >6000 U/L--97% specific
    • Both elevated also in biliary dz, perforation, renal insufficiency
    • Amylase also high in parotitis, macroamylasemia, chronic EtOH

Acute Pancreatitis (continued)

slide6

Initial Eval: RUQ U/S of biliary tree, CT after 48 hours if not improved or complication suspected

    • Don’t worry about MRCP vs ERCP
  • Prognosis
    • APACHE II, Ranson’s, and Balthazar have been validated for mortality
    • Failure of one or more organ system is more clinically useful

Acute Pancreatitis (continued)

slide7

57 yo woman s/p traumatic pancreatitis 8 mos ago presents in F/U. She is asymptomatic. No meds. No EtOH. PE: epigastric fullness, no pain. Amylase 180 U/L. Serial CT Scans reveal an 8 cm cystic lesion with a well-defined capsule in the pancreatic body. No  in 6 mos. Best Management?

A. Conservative

B. Percutaneous drainage

C. ERCP with internal drainage

D. Surgical drainage

E. TPN

fluid collections and pancreatitis
Fluid Collections and Pancreatitis
  • Pancreatitic fluid collection high in amylase may appear in 48 hours, usually resolves
  • Left pleural effusion common
  • Fluid collection with clinical signs of infection should be aspirated to r/o infection
  • Necrosis, within 2 weeks, if infected--surgical debridement
  • Severe pancreatitis with suspected infection: empiric coverage with imipenem or cefuroxime
fluid collections
Fluid collections
  • Pseudocyst develops in 10-15% of pts, requires 1-4 weeks to develop
    • Complications of hemorrhage, rupture, fistula formation
    • Drainage rec’d only if symptomatic or infected
  • Abscess develops 4-6 weeks post acute attack
    • CT guided aspiration 90% accurate
    • Surgical debridement
slide10

Pancreatic Pearls

  • Abdominal Pain and  amylase don’t always equal acute pancreatitis:
    • Acute cholecystitis
    • Intestinal infarction
    • DKA
    • Perforated Ulcer
    • Salpingitis
    • Ectopic pregnancy
    • Perforated Diverticulum
    • Macroamylasemia
chronic pancreatitis
Chronic Pancreatitis
  • 60-70% due to EtOH, usu >10 years.
  • Other causes CF, pancreas divisum, tumor, hyperparathyroidism
  • Loss 80-90% of endocrine/exocrine function develop DM and steatorrhea
  • Increased risk for pancreatic cancer
  • Dx:
    • 1) Ca+ on AXR
    • 2) CT or MRI or EUS or secretin test (bicarb<80 mEq/L)
    • 3) ERCP
complications of chronic pancreatitis
Complications of Chronic Pancreatitis
  • Gastric varices due to splenic vein thrombosis
  • B12 malabsorption
  • Brittle DM, prone to hypoglycemia secondary to loss of pancreatic glucagon
    • No retinopathy or nephropathy
  • Jaundice due to obstruction of CBD as it runs through the pancreatic head
chronic pancreatitis treatment
Chronic Pancreatitis Treatment
  • Low fat diet, less than 25 g/d
  • Pancreatic enzyme replacement has little or no effect on pain but can help with steatorrhea
  • Must be enteric coated or given with PPI because gastric acid inactivates them
  • If pancreatic duct is dilated, ERCP or surgery have shown improvement in pain
pancreatitis pearls
Pancreatitis Pearls
  • Microlithiasis may cause recurrent pancreatitis in setting of no EtOH and no gallstones on U/S
  • Splenic vein thrombosis in severe acute pancreatitis causes gastric not esophageal varices
  • ERCP
    • cholangitis/sepsis
    • TB > 2.5 or dilated CBD on imaging
pancreatic neoplasms
Pancreatic Neoplasms
  • Pancreatic Adenocarcinoma:
    • Classic presentation is painless jaundice
    • Risk Factors: chronic pancreatitis, diabetes mellitus, smokers (2x), perhaps heavy EtOH users
    • >80% present with advanced disease
    • CT is first test, Double duct sign on ERCP, EUS good for staging
    • If no mets then Whipple procedure, rarely curative
cystic neoplasms of the pancreas
Cystic Neoplasms of the Pancreas
  • They happen and need biopsy to r/o cystadenocarcinoma
  • All have malignant potential and need resection
other pancreatic neoplasia
Other Pancreatic Neoplasia
  • Glucagonoma
    • Plasma glucagon usually > 1000pg/dl
    • Scaly necrotizing dermatitis
      • Necrolytic migratory erythema (NME)
    • Wt loss
    • Anemia
    • Hyperglycemia
slide18

Other Pancreatic Neoplasia

  • Insulinoma
  • VIPoma
    • “pancreatic cholera”, profuse watery diarrhea
  • Gastrinoma
    • ZE syndrome, elevated gastrin level (off PPI), think about MEN I
biliary disease
Biliary Disease
  • Cholelithiasis
    • 20% females, 8% of males
    • Obesity, Pregnancy
    • Native American (Pima Indian), Hispanic
    • Oral contraceptive use, Clofibrate tx, TPN
    • Ileal disease (Crohn’s) or resection
    • 80% of stones are radioluscent-cholesterol
      • good case-pt s/p gastric bypass, rapid wt loss--cholesterol stones
cholelithiasis
Cholelithiasis
  • Pigment stones: Clonorchis, Sickle cell dz (i.e., hemolysis)
  • Dx: U/S 90% sensitive; HIDA best for determining cystic duct obstruction
  • Tx:
    • Symptomatic-Elective cholecystectomy
    • If not surgical candidate: Actigall--cholesterol stones only
    • Low suspicion for CBD stone: MRCP or EUS
    • High suspicion CBD stone: ERCP
slide21

70 yo asymptomatic woman undergoes abd U/S after a pulsatile mass is found on physical exam. A 3 cm aortic aneurysm and multiple gallstones are found. The next step in management is:

  • ERCP with sphincterotomy
  • Lithotripsy
  • Elective cholecystectomy
  • Ursodeoxycholic Acid
  • Observation/No treatment
slide22

Asymptomatic: Observation!!!

  • Cholangitis
    • Charcot’s Triad:
      • Fever
      • Biliary colic
      • Jaundice
    • Tx:
      • Abx
      • ERCP for sphincterotomy
other diseases of the gb
Other Diseases of the GB
  • Calcifications of GB wall on X-Ray highly suggestive of canceropen cholecystectomy
  • Emphysematous cholecystitisemergent laparotomy
    • Abx-Gram- and anaerobes, no ceftriaxone (biliary concretions)!
primary biliary cirrhosis
Primary Biliary Cirrhosis
  • EPIDEMIOLOGY
    • 95% women
    • onset 30-65
    • incidence 2.7 per 100,000 person years
primary biliary cirrhosis1
Primary Biliary Cirrhosis
  • EPIDEMIOLOGY
    • clustering in geographic areas
    • prevalence 1000x greater in families of a patient than general population
      • no obvious inheritance pattern
primary biliary cirrhosis2
Primary Biliary Cirrhosis
  • SYMPTOMS / PRESENTATION
    • abnormal LFT’s
    • fatigue
    • pruritus
    • decompensated cirrhosis
primary biliary cirrhosis3
Primary Biliary Cirrhosis
  • SYMPTOMS / PRESENTATION
    • osteoporosis
    • osteomalacia
    • steatorrhea
    • xanthomata
    • hyperlipidemia
primary biliary cirrhosis4
Primary Biliary Cirrhosis
  • ASSOCIATED CONDITIONS
    • rheumatoid arthritis 5-10%
    • Sjogren’s 40-65%
    • scleroderma 5-10%
    • hypothyroidism 20%
primary biliary cirrhosis5
Primary Biliary Cirrhosis
  • PHYSICAL EXAM
    • Skin hyperpigmentation
    • Xanthomas
    • Hepatomegaly
    • Kayser-Fleischer rings (rare)
      • not just Wilson’s
    • Splenomegaly, ascites, etc
primary biliary cirrhosis6
Primary Biliary Cirrhosis
  • LABORATORY
    • Alk phos - may be only abnormality
    • AST/ALT - normal or mild elevation
    • bilirubin - normal early, elevated later
primary biliary cirrhosis7
Primary Biliary Cirrhosis
  • LABORATORY
    • Antimitochondrial antibody
      • sensitivity 95%
      • specificity 98%
    • IgM - elevated
    • Eosinophilia
primary biliary cirrhosis8
Primary Biliary Cirrhosis
  • LABORATORY
    • Hyperlipidemia
      • elevated in > 50%
      • mild LDL and VLDL elevations
      • significantly elevated HDL
      • no known increased risk of CAD
primary biliary cirrhosis9
Primary Biliary Cirrhosis
  • LIVER BIOPSY
    • Diagnosis often made prior to liver biopsy
    • Biopsy may stage the degree of fibrosis (0-4)
primary biliary cirrhosis10
Primary Biliary Cirrhosis
  • NATURAL HISTORY
    • Mahl et al., Yale, Hepatology 1994
    • 250 patients, up to 24 years follow-up
    • Median survival
      • symptomatic - 7.5 years
      • asymptomatic - 16 years
primary biliary cirrhosis11
Primary Biliary Cirrhosis
  • TREATMENT
    • Malabsorption
      • Vitamin D
      • Vitamin A
      • Vitamin E - in advanced disease
      • Vitamin K - in advanced disease
primary biliary cirrhosis12
Primary Biliary Cirrhosis
  • TREATMENT
    • Drugs that didn’t work
      • steroids
      • azathioprine
      • penicillamine
      • silymarin (milk thistle)
      • cyclosporine - effective but toxicities
primary biliary cirrhosis13
Primary Biliary Cirrhosis
  • TREATMENT
    • Ursodeoxycholic acid
      • UDCA decreases plasma and biliary endogenous bile acid concentrations
      • UDCA may decrease immune-mediated destruction of hepatocytes by decreasing the expression of HLA class I and II antigens on hepatocytes, which may diminish recognition by the immune system
primary biliary cirrhosis14
Primary Biliary Cirrhosis
  • TREATMENT
    • Ursodeoxycholic acid
      • 13-15 mg/day
      • Moderate to severe disease
        • decreased likelihood of transplantation or death
        • 47% versus 66% at 4 years
        • meta-analysis showed no benefit but many studies short-term
primary biliary cirrhosis15
Primary Biliary Cirrhosis
  • TREATMENT
    • Ursodeoxycholic acid
      • Mild to moderate disease
        • improvement in LFT’s
        • improved histology
primary biliary cirrhosis16
Primary Biliary Cirrhosis
  • TREATMENT
    • Colchicine
      • mechanism unclear
      • dose 1 mg/day
      • well-tolerated in studies
      • less effective than ursodiol
      • no clear benefit to combination therapy
primary biliary cirrhosis17
Primary Biliary Cirrhosis
  • TREATMENT
    • Methotrexate
      • Dose 0.25 mg/kg PO qweek
      • Conflicting results
      • No long-term efficacy, safety data
primary biliary cirrhosis18
Primary Biliary Cirrhosis
  • TREATMENT
    • Liver Transplantation
      • survival similar to other etiologies of liver disease
      • recurrence after liver transplant uncommon
        • similar appearance to chronic rejection
primary sclerosing cholangitis
Primary Sclerosing Cholangitis
  • Characterized by progressive inflammation, fibrosis, and stricturing of the intrahepatic and extrahepatic bile ducts
primary sclerosing cholangitis1
Primary Sclerosing Cholangitis
  • “Secondary” sclerosing cholangitis
    • prior biliary surgery
    • choledocholithiasis
    • intra-arterial chemo (floxuridine)
    • bacterial cholangitis
    • AIDS cholangiopathy
primary sclerosing cholangitis2
Primary Sclerosing Cholangitis
  • EPIDEMIOLOGY
    • Prevalence 1- 6 per 100,000 in US
    • 70% men
    • mean age at diagnosis 40 years
primary sclerosing cholangitis3
Primary Sclerosing Cholangitis
  • ASSOCIATION WITH IBD
    • Among patients with PSC, ulcerative colitis present in 25-90% (likely 90%)
    • Among patients with ulcerative colitis, PSC present in 5%
    • Less common but seen in Crohn’s
primary sclerosing cholangitis4
Primary Sclerosing Cholangitis
  • PATHOGENESIS
    • Unknown but proposed
      • autoimmune (given association with UC), common ANA, ASMA, ANCA
      • inflammatory reaction in the liver and bile ducts induced by chronic or recurrent entry of bacteria into the portal circulation
      • ischemic damage to bile ducts
primary sclerosing cholangitis5
Primary Sclerosing Cholangitis
  • DIAGNOSIS
    • Gold standard - ERCP
      • MRCP also
    • most patients asymptomatic with abnormal LFT’s
    • consider if IBD and elevated alk phos
primary sclerosing cholangitis6
Primary Sclerosing Cholangitis
  • LABORATORY
    • alk phos & bili fluctuate
    • AST/ALT normal or up to 200
primary sclerosing cholangitis7
Primary Sclerosing Cholangitis
  • LABORATORY
    • elevated IgG 30%
    • elevated IgM 40-50%
    • p-ANCA 30-80%
    • HLA DRw52a 0-100%
primary sclerosing cholangitis8
Primary Sclerosing Cholangitis
  • LIVER BIOPSY
    • sampling likely so not a good diagnostic tool
    • may stage disease
primary sclerosing cholangitis9
Primary Sclerosing Cholangitis
  • LOCATION
    • Intra- & extrahepatic bile ducts: 87%
    • Intrahepatic bile ducts alone: 11%
    • Extrahepatic bile ducts alone: 2%

Kaplan, NEJM 1995

primary sclerosing cholangitis10
Primary Sclerosing Cholangitis
  • PRESENTATIONS
    • Ascending cholangitis
    • Abnormal LFT’s
    • Pruritus
primary sclerosing cholangitis11
Primary Sclerosing Cholangitis
  • NATURAL HISTORY
    • complications vary
      • biliary - ascending cholangitis
      • liver failure - portal hypertension, etc
      • cholangiocarcinoma
primary sclerosing cholangitis12
Primary Sclerosing Cholangitis
  • NATURAL HISTORY
    • mean survival 12 years after diagnosis
      • worse if symptomatic at diagnosis
primary sclerosing cholangitis13
Primary Sclerosing Cholangitis
  • TREATMENT
    • No proven medical therapy
      • D-penicillamine
      • Steroids
      • Cyclosporine, Tacrolimus
      • Methotrexate
      • Azathioprine, 6-MP
      • Ursodeoxycholic acid (small study, benefit to  dose)
primary sclerosing cholangitis14
Primary Sclerosing Cholangitis
  • TREATMENT
    • Relieve biliary obstruction
      • risk of infection
    • Dominant stricture
      • r/o cholangiocarcinoma
      • dilate or stent
primary sclerosing cholangitis15
Primary Sclerosing Cholangitis
  • TREATMENT
    • Liver Transplantation
      • survival similar to other etiologies of liver disease
      • disadvantage if symptoms due to cholangitis and not liver failure in MELD
        • living donor?
primary sclerosing cholangitis16
Primary Sclerosing Cholangitis
  • CHOLANGIOCARCINOMA
    • 10-15% lifetime risk
    • increased if IBD or cirrhosis
    • contraindication to liver transplant
      • protocol for aggressive chemotherapy
primary sclerosing cholangitis17
Primary Sclerosing Cholangitis
  • CHOLANGIOCARCINOMA
    • Diagnosis difficult
    • CT/MRI - low sensitivity
    • CA 19-9 - low sensitivity
autoimmune hepatitis
Autoimmune Hepatitis
  • EPIDEMIOLOGY
    • Female > Male 4:1
    • Two peaks
      • 20’s and Middle age
      • also seen in children
    • 50-200 cases/million
autoimmune hepatitis1
Autoimmune Hepatitis
  • SYMPTOMS/PRESENTATION
    • Abdominal pain
    • fever
    • anorexia
    • malaise
autoimmune hepatitis2
Autoimmune Hepatitis
  • SYMPTOMS/PRESENTATION
    • Acute or chronic disease
    • 30 - 80 % cirrhotic at presentation
autoimmune hepatitis3
Autoimmune Hepatitis
  • ASSOCIATED CONDITIONS
    • Arthropathy
    • Ulcerative colitis
    • Sjogren’s syndrome
    • Autoimmune thyroiditis
    • Fibrosing Alveolitis
    • Glomerulonephritis
autoimmune hepatitis4
Autoimmune Hepatitis
  • DIAGNOSIS
  • PATHOLOGY
    • Interface hepatitis
    • Lymphocytes and plasma cells
    • Bridging necrosis
    • Cirrhosis
autoimmune hepatitis5
Autoimmune Hepatitis
  • CLASSIFICATION
  • Type 1
    • ANA, anti-smooth muscle antibody
  • Type 2
    • anti-LKM, liver cytosol antigen
    • girls, young women
autoimmune hepatitis6
Autoimmune Hepatitis
  • CLASSIFICATION
  • Overlap Syndrome
    • path  autoimmune hepatitis
    • serology  PBC (+AMA)
  • Autoimmune cholangiopathy
    • path  PBC
    • serology  ANA, asma
autoimmune hepatitis7
Autoimmune Hepatitis
  • TREATMENT
    • Corticosteroids
      • acute management
    • Azathioprine
      • goal - maintain remission
      • 2 mg/kg per day
      • goal to d/c Prednisone
slide70
NASH
  • Nonalcoholic steatohepatitis
  • Nonalcoholic fatty liver disease (NAFLD)
slide71
NASH
  • DEFINITION
    • liver biopsy with macrovesicular steatosis & inflammation
    • minimal or no EtOH
    • negative serologic work-up
slide72
NASH
  • EPIDEMIOLOGY
    • #1 cause of liver disease?
    • Women > men
    • Most 40-60
      • reported in children
slide73
NASH
  • ASSOCIATED CONDITIONS
    • obesity
    • type 2 diabetes mellitus
    • hyperlipidemia
    • medications
    • obesity bypass procedures
    • TPN
slide74
NASH
  • DIAGNOSIS
    • liver biopsy
      • confirms or excludes dx
      • negative serologic work-up
slide75
NASH
  • TREATMENT
    • treat underlying condition
      • obesity, DM, lipids
    • stay tuned...
alcoholic hepatitis
Alcoholic Hepatitis
  • EPIDEMIOLOGY
    • alcohol
      • cirrhosis  80 gm/d EtOH for 10-20 years
    • other factors
      • female gender
        • reduced gastric ADH activity
        • size
      • co-existing HBV, HCV
alcoholic hepatitis1
Alcoholic Hepatitis
  • SYMPTOMS
    • fever
    • hepatomegaly
    • jaundice
    • anorexia
alcoholic hepatitis2
Alcoholic Hepatitis
  • DIAGNOSIS
    • liver biopsy
      • steatosis, inflammation
    • AST > 2x ALT
alcoholic hepatitis3
Alcoholic Hepatitis
  • PROGNOSIS
    • liver failure
      • coagulopathy
      • encephalopathy
    • Discriminant function =

(4.6 x [PT - control PT]) + (serum bili, mg/dl)

    • DF > 32: mortality 35-45%
alcoholic hepatitis4
Alcoholic Hepatitis
  • TREATMENT
    • Supportive care
    • Who gets steroids?
      • DF > 32
      • Encephalopathy
      • No infection, no GI bleeding
abnormal liver tests
Abnormal Liver Tests
  • Hepatocellular - AST, ALT 
  • Cholestatic - alkaline phosphatase 
    • bilirubin can be elevated in both
abnormal liver tests1
Abnormal Liver Tests
  • AST 124 U/L
  • ALT 157 U/L
  • Alk phos 149 U/L
  • T. bili 1.6 mg/dl
abnormal liver tests2
Abnormal Liver Tests
  • AST/ALT mildly elevated (<250 U/L)
    • chronic viral hepatitis
      • HCV Ab, HBV surface antigen
    • alcoholic hepatitis (AST > ALT)
      • drug reaction - consider d/c
      • NSAIDs, statins, antibiotics (INH)
    • hemochromatosis (Fe/TIBC > 45%)
    • steatosis, steatohepatitis
abnormal liver tests3
Abnormal Liver Tests
  • AST/ALT mildly elevated (<250 U/L)
    • less common causes
    • autoimmune hepatitis
      • ANA, ASMA, a-LKM
    • Wilson’s disease
      • age < 40; check ceruloplasmin, K-F rings
    • Alpha-1-antitrypsin deficiency
      • emphysema; alpha-1-antitrypsin level
abnormal liver tests4
Abnormal Liver Tests
  • AST/ALT mildly elevated (<250 U/L)
    • non-hepatic causes
    • muscle source
    • hypothyroidism
    • celiac disease
      • diarrhea, Fe deficiency; anti-endomysial IgA
    • adrenal insufficiency
abnormal liver tests5
Abnormal Liver Tests
  • AST/ALT mildly elevated (<250 U/L)
    • negative serologic work-up
    • consider liver biopsy if persistently abnormal
abnormal liver tests6
Abnormal Liver Tests
  • AST 1480 U/L
  • ALT 1704 U/L
  • Alk phos 229 U/L
  • T. bili 4.8 mg/dl
abnormal liver tests7
Abnormal Liver Tests
  • AST/ALT  > 10x ULN
    • acute viral hepatitis
      • hep A IgM
      • hep B core IgM
      • hep D
    • autoimmune hepatitis
    • shock liver (ischemic hepatitis)
    • drug or toxin (acetaminophen)
abnormal liver tests8
Abnormal Liver Tests
  • AST/ALT  > 10x ULN
    • Rarer forms
    • acute Budd-Chiari syndrome
    • veno-occlusive disease
    • HELLP syndrome
    • acute fatty liver of pregnancy
abnormal liver tests9
Abnormal Liver Tests
  • AST/ALT  > 10x ULN
    • Acute Liver Failure
    • Elevated PT
      •  factor V
    • Encephalopathy
      • If discharge patient, clarify supervision
    • Transfer to Transplant Center
abnormal liver tests10
Abnormal Liver Tests
  • Bilirubin
    • unconjugated
      • Overproduction of bilirubin or impaired uptake, conjugation
      • tightly bound to albumin so not filtered and not present in urine
    • conjugated
      • impaired excretion into bile ductules
      • present in the urine
abnormal liver tests11
Abnormal Liver Tests
  • Unconjugated bilirubin
    • hemolysis
    • impaired bilirubin uptake
      • CHF
      • Portosystemic shunts
      • Certain drugs - rifampin, probenecid
abnormal liver tests12
Abnormal Liver Tests
  • Unconjugated bilirubin
    • hemolysis
    • impaired bilirubin uptake
    • impaired bilirubin conjugation
      • Gilbert’s
      • Crigler-Najjar
      • hyperthyroidism
      • cirrhosis
      • Wilson’s disease
abnormal liver tests13
Abnormal Liver Tests
  • Unconjugated bilirubin
    • Gilbert’s Syndrome
      • Uridinediphosphoglucuronate glucuronosyltransferases (UGTs) mediate glucuronidation
      • Mutation of UGT1A
      • 9% western world homozygous
      • 30% heterozygous
        • Slightly higher bili
abnormal liver tests14
Abnormal Liver Tests
  • Unconjugated bilirubin
    • Gilbert’s Syndrome
      • Bilirubin
        • Usually < 3 mg/dl, rarely > 6
      • Factors
        • Fasting
        • Stress (surgery, etc)
        • Infection
abnormal liver tests15
Abnormal Liver Tests
  • Unconjugated bilirubin
    • Gilbert’s Syndrome
      • Diagnosis
        • rise in bilirubin concentration following a low lipid, 400 kcal diet
        • administration of IV nicotine
        • seldom necessary in clinical practice
abnormal liver tests16
Abnormal Liver Tests
  • Conjugated bilirubin
    • Extrahepatic cholestasis
      • PSC
      • intrinsic & extrinsic tumors
      • AIDS cholangiopathy
      • cholelithiasis
      • parasites - ascaris lumbricoides, liver flukes
abnormal liver tests17
Abnormal Liver Tests
  • Conjugated bilirubin
    • Intrahepatic cholestasis
      • Viral hepatitis
      • Alcoholic hepatitis
      • Nonalcoholic fatty liver disease
      • PBC
      • Drugs, toxins
      • Sepsis
abnormal liver tests18
Abnormal Liver Tests
  • Conjugated bilirubin
    • Intrahepatic cholestasis
      • Infiltrative diseases - sarcoidosis, amyloid, lymphoma
      • TPN
      • Pregnancy
      • Cirrhosis
      • Dubin Johnson, Rotor syndrome
abnormal liver tests19
Abnormal Liver Tests
  • AST 32 U/L
  • ALT 29 U/L
  • Alk phos 472 U/L
  • T. bili 1.0 mg/dl
  • (5’-nucleotidase )
abnormal liver tests20
Abnormal Liver Tests
  • Elevated alkaline phosphatase
    • primary biliary cirrhosis
    • primary sclerosing cholangitis
    • partial bile duct obstruction
    • drugs (androgenic steroids, phenytoin)
    • sarcoidosis
    • metastatic cancer
ad