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An Approach to Abnormal LFTs

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  1. An Approach to Abnormal LFTs Robert C. Lowe, M.D. Boston Medical Center July 17, 2013

  2. INR ALP AST T. BIL GGT ALT ALB

  3. Chessboard

  4. AST ALT ALB ALP GGT T. BIL

  5. Case 1 30 year old woman 4 days of malaise, fevers to 101, nausea 1 day of RUQ pain and jaundice Exam - T 100.5 Icteric sclerae and jaundice Tender hepatomegaly, no spleen tip

  6. Case 1 AST 1535 WBC 8.1 ALT 1602 HCT 41 ALP 128 PLT 353 T. Bil 7.3 Albumin 3.9

  7. Transaminases AST - aspartate aminotransferase ALT - alanine aminotransferase Released when hepatocytes are injured - a sign of necrosis.

  8. AST - less specific for liver disease Muscle (skeletal and cardiac) Kidney Erythrocytes ALT - very little outside of liver. A better marker of liver disease.

  9. Differential Diagnosis Sky high transaminases > 15x normal

  10. Differential Diagnosis Sky high transaminases > 15x normal Virus Drug Ischemia } >80% of cases

  11. History and Exam Points AST/ALT>1000 Virus Toxin Ischemia

  12. History and Exam Points IVDU Arthralgias Sexual partners Urticaria Travel Herpetic lesions Food exposures Stigmata of liver dz AST/ALT>1000 Virus Toxin Ischemia

  13. History and Exam Points IVDU Arthralgias Sexual partners Urticaria Travel Herpetic lesions Food exposures Stigmata of liver dz AST/ALT>1000 Virus Toxin Ischemia

  14. History and Exam Points IVDU Arthralgias Sexual partners Urticaria Travel Herpetic lesions Food exposures Stigmata of liver dz Meds OTC meds Herbs and supplements AST/ALT>1000 Virus Toxin Ischemia

  15. History and Exam Points IVDU Arthralgias Sexual partners Urticaria Travel Herpetic lesions Food exposures Stigmata of liver dz Meds OTC meds Herbs and supplements Recent surgery Hypotension Cardiac arrest CMP AST/ALT>1000 Virus Toxin Ischemia

  16. AST/ALT>1000

  17. AST/ALT>1000 Autoimmune Wilson Disease Bile Duct Obstruction Budd-Chiari

  18. Clinical Clues Female gender Personal or Family Hx of autoimmune dz AST/ALT>1000 Autoimmune Wilson Disease Bile Duct Obstruction Budd-Chiari

  19. Clinical Clues Female gender Personal or Family Hx of autoimmune dz ANA ASMA Ig levels AST/ALT>1000 Autoimmune Wilson’s Disease Bile Duct Obstruction Budd-Chiari

  20. AST/ALT>1000 Autoimmune Wilson’s Disease Bile Duct Obstruction Budd-Chiari

  21. Clinical Clues Male gender < age 40 Neuropsychiatric syndrome Psychosis Movement disorder AST/ALT>1000 Autoimmune Wilson’s Disease Bile Duct Obstruction Budd-Chiari

  22. Clinical Clues Male gender < age 40 Neuropsychiatric syndrome Psychosis Movement disorder Low ALP Hemolysis Ceruloplasmin less useful in acute disease AST/ALT>1000 Autoimmune Wilson’s Disease Bile Duct Obstruction Budd-Chiari

  23. KF Rings

  24. Head CT

  25. AST/ALT>1000 Autoimmune Wilson Disease Bile Duct Obstruction Budd-Chiari

  26. AST/ALT>1000 Autoimmune Wilson Disease Bile Duct Obstruction Budd-Chiari Clinical Clues H/O biliary colic or GS disease FH of gallstones RUQ pain N/V Transaminases fall rapidly - over 1-3 days U/S often diagnostic, but may need further imaging with MRCP/ERCP

  27. AST/ALT>1000 Autoimmune Wilson Disease Bile Duct Obstruction Budd-Chiari

  28. Clinical Clues OCP use Prior venous thrombosis Myeloproliferative disorder Malignancy Abdominal Pain Ascites AST/ALT>1000 Autoimmune Wilson Disease Bile Duct Obstruction Budd-Chiari

  29. Laboratory Testing • Hepatitis A - IgM and IgG • Hepatitis B - sAg, cAb, eAg, HBV DNA • Hepatitis C - RNA level • ANA, ASMA, Ig levels • RUQ U/S with Doppler Study • Consider other viral serologies, ceruloplasmin, MRCP

  30. Prognostic Features

  31. Prognostic Features • Coagulopathy • INR elevation • Encephalopathy • Mental Status • Asterixis • Apraxia

  32. Case 2 • Asymptomatic 45 year-old woman • Cholesterol 245, Trig 266 • No significant FH • No meds • Works as an accountant

  33. Case 2 AST 84 WBC 6.6 ALT 46 HCT 37 ALP 121 PLT 165 T. Bil 0.8 ALB 3.7

  34. Alcoholic LFT Pattern • AST/ALT > 2:1 • Absolute AST and ALT < 300 • GGT elevation is helpful, but nonspecific.

  35. Alcoholic LFT Pattern WHY? ALT synthesis is decreased in EtOH hepatitis. Partially due to pyridoxine deficiency - may correct with B6 therapy.

  36. Case 2 AST 84 WBC 6.6 ALT 46 HCT 37 ALP 121 PLT 165 T. Bil 0.8 ALB 3.7

  37. Case 2 AST 84 WBC 6.6 ALT 89 HCT 37 ALP 121 PLT 165 T. Bil 0.8 ALB 3.7

  38. Mildly Elevated Transaminases A B C DE F G H

  39. Mildly Elevated Transaminases Alcohol / Autoimmune B Hepatitis C Hepatitis Drug Exotic Wilson Disease Alpha-1-antitrypsin deficiency Fatty liver Gluten sensitive enteropathy Hemochromatosis

  40. Mildly Elevated Transaminases Alcohol / Autoimmune B Hepatitis C Hepatitis Drug Exotic Wilson Disease Alpha-1-antitrypsin deficiency Fatty liver Gluten sensitive enteropathy Hemochromatosis Thyroid disease, myopathies

  41. Mildly Elevated Transaminases Alcohol / Autoimmune Alcohol Hx B Hepatitis HBsAg, HBcAb, HBsAb C HepatitisHCV Ab Drug Drug Hx Exotic Wilson Disease Alpha-1-antitrypsin deficiency Fatty liver RUQ U/S, TG Gluten sensitive enteropathy Hemochromatosis Thyroid disease, myopathies

  42. Mildly Elevated Transaminases Alcohol / Autoimmune ANA, ASMA, Ig levels B HepatitisHBsAg, HBcAb, HBsAb C HepatitisHCV Ab Drug Drug Hx Exotic Wilson Disease Alpha-1-antitrypsin deficiency Fatty liver RUQ U/S, TG Gluten sensitive enteropathy Hemochromatosis Fe, TIBC, Ferritin Thyroid disease, myopathies

  43. Mildly Elevated Transaminases Alcohol / Autoimmune ANA, ASMA, Ig levels B Hepatitis HBsAg, HBcAb, HBsAb C HepatitisHCV Ab Drug Drug Hx Exotic Wilson Disease Ceruloplasmin Alpha-1-antitrypsin deficiency A-1-AT level Fatty liver RUQ U/S, TG Gluten sensitive enteropathy Hemochromatosis Fe, TIBC, Ferritin Thyroid disease, myopathies

  44. Mildly Elevated Transaminases Alcohol / Autoimmune ANA, ASMA, Ig levels B Hepatitis HBsAg, HBcAb, HBsAb C HepatitisHCV Ab Drug Drug Hx Exotic Wilson Disease Ceruloplasmin Alpha-1-antitrypsin deficiency A-1-AT level Fatty liver RUQ U/S, TG Gluten sensitive enteropathy Anti-TTG Hemochromatosis Fe, TIBC, Ferritin Thyroid disease, myopathies TSH, CK, Aldolase