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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 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 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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slide1
CLINICAL APPROACH TO THE PATIENT WITH ABNORMAL LIVER TEST RESULTSDAVID E. KATZ, MDPGY-3WRAMC DOMINTERN LECTURE SERIES ‘98
slide2
OBSTRUCTION
  • INFLAMMATION
  • SYNTHETIC ABILITY
  • DETOXIFICATION
  • PORTAL HYPERTENSION
slide13
LIVER “FUNCTION” TEST
    • GALACTOSE CLEARANCE
    • AMINOPYRINE CLEARANCE TEST
  • INCIDENCE OF CLINICALLY SIGNIFICANT LIVER DISEASE =1%
clinical assessment of the patient
CLINICAL ASSESSMENT OF THE PATIENT
  • 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”)
family history
FAMILY HISTORY
  • INDIRECT HYPERBIL- HEMOLYSIS OR GILBERTS SYNDROME.
  • DIRECT HYPERBIL- DUBIN-JOHNSON
  • HX OF SEVERE LIVER DZ: WILSON’S DZ, HEMOCHROMATOSIS, ALPHA-1-AT
history
HISTORY
  • 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.
physical exam
PHYSICAL EXAM

GO

NUTS!!!!

physical exam18
PHYSICAL EXAM
  • PALPABLE GB- EXTRAHEPATIC CHOLESTASIS
  • BRUIT- ANUERYSM/TR
  • KAYSER-FLEISCHER RINGS: WILSONS DZ
  • MURPHY SIGN: ACUTE CHOLECYSTITIS
bilirubin
BILIRUBIN
  • 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)
transaminases
TRANSAMINASES
  • ENZYMES INVOLVED IN THE TRANSFER OF AMINO GROUPS OF ASPARTATE AND ALANINE TO KETOGLUTARIC ACID.
transaminases21
TRANSAMINASES
  • AST: GLUTAMIC-OXALOACETIC TRANSAMINASE:
    • CARDIAC
    • SKELETAL
    • KIDNEY
    • BRAIN
    • LIVER
transaminase
TRANSAMINASE
  • ALT: GLUTAMATE PYRUVATE TRANSAMINASE
    • ALMOST EXCLUSIVELY IN LIVER
  • AST W/O ALT
    • CARDIAC DZ
    • MACRO-AST
ast alt ratio
AST/ALT RATIO
  • 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
transaminases24
TRANSAMINASES
  • 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
transaminases25
TRANSAMINASES
  • >10,000 IU/L: ACETAMINOPHEN AND IN HERPES SIMPLEX VIRUS.
  • MEDS THAT INC AST:
slide26
MEDS
  • ACET/ NSAIDS
  • ACE’I
  • NICOTINIC ACID
  • ABX: INH, SULFA, E-MYCIN
  • ANTIFUNGAL: GRISEOFULVIN/FLUCONAZOLE
transaminitis
TRANSAMINITIS
  • NASH
  • THYROID DZ
alkaline phosphatase
ALKALINE PHOSPHATASE
  • FAMILY OF ENZYMES THAT CATALYZE HYDROLYSIS OF PHOSPHATE ESTERS AT AN ALKALINE PH.
  • BONE, PLACENTA, INTESTINE, KIDNEY AND LIVER.
  • 80% (BONE/LIVER)
alk phos
ALK PHOS
  • CHOLESTASIS
    • INTRAHEPATIC
    • EXTRAHEPATIC (GALLSTONES/TUMOR)
    • LOCALIZED (HEPATOMA)
    • PATCHY (GRANULOMATOUS DZ)
  • CHF, HYPERTHYROIDISM, LYMPHOMA, HYPERNEPHROMA
alk phos30
ALK PHOS
  • GAMMA-GLUTAMYLTRANSFERASE (GGT)
  • IF INC DISPROPORTIONATELY TO BILI INCREASE --->SARCOID, TB, FUNGAL, LYMPHOMA
    • PBC/PSC
alk phos31
ALK PHOS
  • 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
alk phos32
ALK PHOS
  • INTRAHEPATIC CHOLESTASIS
    • PBC, DRUGS
  • EXTRAHEPATIC CHOLESTASIS
    • CBD STONES, STRICTURES, PANCREATIC CANCER
albumen
ALBUMEN
  • SYTH. BY THE LIVER
  • T1/2 3 WEEKS
  • DEC USUALLY INDICATES LIVER DISEASE OF MORE THAN 3 WEEKS
  • SEPSIS
prothrombin time
PROTHROMBIN TIME
  • VIT K DEP CLOTTING FACTORS
  • VIT K NOT ABSORBED (CHOLESTASIS), HEPATOCELLULAR DISEASE.
  • MORE SENSITIVE THAN ALBUMEN
  • PROLONGATION CORRELATES WITH DISEASE
other test
OTHER TEST
  • IMMUNOGLOBULINS
    • IgM INCREASE WITH PBC
    • ANA >1:160 HOMGENEOUS W/ SMOOTH MUSCLE AB +.
    • AMA W/ PBC
  • WILSONS : LOW SERUM COPPER/CERULOPLASM
other tests
OTHER TESTS
  • HEMOCHROMATOSIS: TRANSFERRIN SAT >55%, FERRITIN >1000 UG/L
  • A-1-AT DEF: LUNG DZ, A-1-AT LEVELS ARE <20 MG/DL
  • VIRAL SEROLOGIES