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CLINICAL APPROACH TO THE PATIENT WITH ABNORMAL LIVER TEST RESULTS DAVID E. KATZ, MD PGY-3 WRAMC DOM INTERN LECTURE SER - PowerPoint PPT Presentation


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CLINICAL APPROACH TO THE PATIENT WITH ABNORMAL LIVER TEST RESULTS DAVID E. KATZ, MD PGY-3 WRAMC DOM INTERN LECTURE SERIES ‘98. OBSTRUCTION INFLAMMATION SYNTHETIC ABILITY DETOXIFICATION PORTAL HYPERTENSION. OBSTRUCTION. OBSTRUCTION: TBIL, DBIL, ALK-P. INFLAMMATORY.

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CLINICAL APPROACH TO THE PATIENT WITH ABNORMAL LIVER TEST RESULTSDAVID E. KATZ, MDPGY-3WRAMC DOMINTERN LECTURE SERIES ‘98


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  • OBSTRUCTION

  • INFLAMMATION

  • SYNTHETIC ABILITY

  • DETOXIFICATION

  • PORTAL HYPERTENSION








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  • LIVER “FUNCTION” TEST CONTROL.

    • GALACTOSE CLEARANCE

    • AMINOPYRINE CLEARANCE TEST

  • INCIDENCE OF CLINICALLY SIGNIFICANT LIVER DISEASE =1%


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CLINICAL ASSESSMENT OF THE PATIENT CONTROL.

  • HEPATOCELLULAR NECROSIS/VIRAL HEPATITIS: ANOREXIA/N/V/F.

  • CHOLESTASIS/INAD. BILE FLOW: DEEP JAUNDICE, PRURITIS, CLAY COLORED STOOLS, DARK URINE.

  • CHOLESTASIS: INTRAHEPATIC/EXTRAHEPATIC (COLIC, FEVER, CHILLS-STONES/ “T”)


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FAMILY HISTORY CONTROL.

  • INDIRECT HYPERBIL- HEMOLYSIS OR GILBERTS SYNDROME.

  • DIRECT HYPERBIL- DUBIN-JOHNSON

  • HX OF SEVERE LIVER DZ: WILSON’S DZ, HEMOCHROMATOSIS, ALPHA-1-AT


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HISTORY CONTROL.

  • SEXUAL HISTORY, TRAVEL, ETOH, DRUGS, ?BLOOD TRANSFUSION, ?NEEDLE STICKS, RAW OYSTERS

  • HEMATOLOGIC DISEASE

  • CARDIAC DZ/IBD/DIABETES/SKIN PIGMENTATION/CARDIAC DZ/ARTHRITIS/HYPOGONADISM/ THYROID DISEASE.


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PHYSICAL EXAM CONTROL.

GO

NUTS!!!!


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PHYSICAL EXAM CONTROL.

  • PALPABLE GB- EXTRAHEPATIC CHOLESTASIS

  • BRUIT- ANUERYSM/TR

  • KAYSER-FLEISCHER RINGS: WILSONS DZ

  • MURPHY SIGN: ACUTE CHOLECYSTITIS


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BILIRUBIN CONTROL.

  • TBIL <1.1 MG/DL (70% INDIRECT)

  • UNCONGUGATED: HEMOLYSIS/GILBERTS (TBIL<6.0)

  • CONJUGATED: HEPATOCELLULAR DYSFUNCTION OR CHOLESTASIS

  • CBD OBS: STONES=15 (>30, EXTRAHEPATIC OBSTR UNLIKELY)


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TRANSAMINASES CONTROL.

  • ENZYMES INVOLVED IN THE TRANSFER OF AMINO GROUPS OF ASPARTATE AND ALANINE TO KETOGLUTARIC ACID.


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TRANSAMINASES CONTROL.

  • AST: GLUTAMIC-OXALOACETIC TRANSAMINASE:

    • CARDIAC

    • SKELETAL

    • KIDNEY

    • BRAIN

    • LIVER


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TRANSAMINASE CONTROL.

  • ALT: GLUTAMATE PYRUVATE TRANSAMINASE

    • ALMOST EXCLUSIVELY IN LIVER

  • AST W/O ALT

    • CARDIAC DZ

    • MACRO-AST


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AST/ALT RATIO CONTROL.

  • AST: BOTH CYTOSOL AND MITO

  • ALT: CYTOSOL

  • ETOH: DAMAGE TO MITOCHONDRIA

    • ETOH LIVER DZ/PYRIDOXINE DEF

    • AST NOT >250 U/L

    • RATIO LESS USEFUL IN CHRONIC LIVER DZ

  • VIRAL DZ: ALT>AST


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TRANSAMINASES CONTROL.

  • CHOLEDOCHOLITHIASIS: AST EARLIEST ABNORMALITY, TRANSIENT

  • DRUG/VIRAL: RISE TO LOW 1000’S IN 1-2 WEEKS.

  • ISCHEMIC HEPATITIS: ACUTE INCREASE (10K IU/L) RETURN WITHIN A WEEK


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TRANSAMINASES CONTROL.

  • >10,000 IU/L: ACETAMINOPHEN AND IN HERPES SIMPLEX VIRUS.

  • MEDS THAT INC AST:


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MEDS CONTROL.

  • ACET/ NSAIDS

  • ACE’I

  • NICOTINIC ACID

  • ABX: INH, SULFA, E-MYCIN

  • ANTIFUNGAL: GRISEOFULVIN/FLUCONAZOLE


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TRANSAMINITIS CONTROL.

  • NASH

  • THYROID DZ


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ALKALINE PHOSPHATASE CONTROL.

  • FAMILY OF ENZYMES THAT CATALYZE HYDROLYSIS OF PHOSPHATE ESTERS AT AN ALKALINE PH.

  • BONE, PLACENTA, INTESTINE, KIDNEY AND LIVER.

  • 80% (BONE/LIVER)


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ALK PHOS CONTROL.

  • CHOLESTASIS

    • INTRAHEPATIC

    • EXTRAHEPATIC (GALLSTONES/TUMOR)

    • LOCALIZED (HEPATOMA)

    • PATCHY (GRANULOMATOUS DZ)

  • CHF, HYPERTHYROIDISM, LYMPHOMA, HYPERNEPHROMA


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ALK PHOS CONTROL.

  • GAMMA-GLUTAMYLTRANSFERASE (GGT)

  • IF INC DISPROPORTIONATELY TO BILI INCREASE --->SARCOID, TB, FUNGAL, LYMPHOMA

    • PBC/PSC


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ALK PHOS CONTROL.

  • PITFALLS: DONE IN FASTING STATE;

    • PT WITH O/B BLOOD GROUP ARE SECRETORS AND CAN HAVE INC ALK-PHOS AFTER EATING A FATTY MEAL DUE TO THE RELEASE OF THE INTESTINAL ENZYME

  • LOW IN HYPOTHYROIDISM, WILSONS DZ, HEMOLYSIS, AND CONG. HYPOPHOSPHTEMIA


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ALK PHOS CONTROL.

  • INTRAHEPATIC CHOLESTASIS

    • PBC, DRUGS

  • EXTRAHEPATIC CHOLESTASIS

    • CBD STONES, STRICTURES, PANCREATIC CANCER


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ALBUMEN CONTROL.

  • SYTH. BY THE LIVER

  • T1/2 3 WEEKS

  • DEC USUALLY INDICATES LIVER DISEASE OF MORE THAN 3 WEEKS

  • SEPSIS


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PROTHROMBIN TIME CONTROL.

  • VIT K DEP CLOTTING FACTORS

  • VIT K NOT ABSORBED (CHOLESTASIS), HEPATOCELLULAR DISEASE.

  • MORE SENSITIVE THAN ALBUMEN

  • PROLONGATION CORRELATES WITH DISEASE


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OTHER TEST CONTROL.

  • IMMUNOGLOBULINS

    • IgM INCREASE WITH PBC

    • ANA >1:160 HOMGENEOUS W/ SMOOTH MUSCLE AB +.

    • AMA W/ PBC

  • WILSONS : LOW SERUM COPPER/CERULOPLASM


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OTHER TESTS CONTROL.

  • HEMOCHROMATOSIS: TRANSFERRIN SAT >55%, FERRITIN >1000 UG/L

  • A-1-AT DEF: LUNG DZ, A-1-AT LEVELS ARE <20 MG/DL

  • VIRAL SEROLOGIES


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