evaluating abnormal liver enzymes - rutland

what is not one of the functions of the liver?

production of liver enzymes

T/F: liver enzyme measurements are liver function tests

F

liver function tests

albumin

bilirubin

INR

two patterns of liver enzyme elevation

hepatocellular AST/ALT

cholestatic ALP

meds, alcohol

viral hepatitis

hemochromatosis

autoimmune hep

wilsons

alpha 1 antitrypsin def

steatosis

hepatocellular

meds alcohol

obstruction

tumors

primary biliary cholangitis

primary sclerosing cholangitis

granulomatous liver disease

cholestatic

strategy for hepatocellular

serolgoic evaluation

strat for cholestatic

imaging studies

common culprits of med induced liver disease

OTC and supplements

drug induced liver injury diagnosis

exclusion

AST:ALT ratio of 2:1 or 3:1

AST and ALT NEVER >500 IU, rarely over 200 IU

alcoholic liver disease

liver assoc enzymes (LAE) >500 and <1500

viral hepatitis

med toxicity

LAE >2000

acetaminophen toxicity

ischemic injury

AST:ALT ratio in hepatocellular disease: chronic viral hep

variable, ~1

excess iron accumulation in organs

hemochromatosis

hemochromatosis diagnosis

elevated transferrin sat

C282Y homozygous (genetic testing)

elevated ALT, AST (>10X ULN)

increased gamma globulin

increased IgG

low albumin, prolonged prothrombin time

autoimmune hepatitis

autoimmune hepatitis diagnosis

ANA

SMA

liver biopsy

ANA, SMA

pANCA, SLA/LP

all ages

thyroiditis, UC, snyovitis

tx failure uncommon

type 1 AI hepatitis

antiLKM1

anti LC1

2-14 yrs

vitiligo, T1DM, thyroiditis

tx failure common

type 2 autoimmune hepatitis

low ALP + AST:ALT high (up to 4:1) in a young patient

wilsons disease

decreased ceruloplasmin, increased 24h urine copper

wilsons disease

liver + pulmonary disease (early lower lobe emphysema)

a1 antitrypsin deficiency

diagnosis for a1 antitrypsin def

dec antitrypsin level

PiZZ phenotype

PAS-D positive globules

PAS stain after diastase digestion

alpha 1 antitrypsin globules

small bowel disease, sensitive to gliadin

inflammation, epithelial damage, malabsorption

liver → innocent bystander

celiac sprue

isolated increased liver enzymes

unexplained transaminitis

celiac

elevated liver enzymes, negative diagnositc evaluation

female, obese, diabetic

hepatic steatosis

hepatic manifestation of metabolic syndrome

fatty liver:

1. increased abdominal girth (m >40, f >35)

2. elevated triglycerides (>150

3. low hdl (m <40, women <50)

4. hyperglycemia (FBS >= 100)

   1. HTN (>130/85)

fat without inflammation, good prog rare progress

steatosis fatty liver

fat WITH inflammation, may progress to cirrhosis

steathepatitis

hepatic steatosis

steatohepatitis

steatohepatitis, pericellular fibrosis

steatohepatitis cirrhosis

may become most common cause of cirrhosis, sig cardiac morbidity and mortality

FAtty liver disease/MAFLD

approach to elevated LFTs

history (med and alcohol)

hep b and c serologies

iron studies

ceruloplasmin, urine coppers

a1antittrypsin phenotype

cholestatic injury initial eval

exclude biliary obstruction and liver mass lesions

RUQ US

common cause cholestatic injury

drug induced liver injury

stop sus meds

first step in cholestatic patterns

RUQ US

AI disorder of biliary epithelium

pruritus and hepatomegaly

asymptomatic AP elevation

primary biliary cholangitis

diagnosis for primary biliary cholangitis

antimitochondrial antibody (AMA)

Lab: marked AP elevation

biopsy: unusual

tx for PBC

ursodeoxycholic acid

immune mediated destruction of small intrahepatic bile ducts

PBC

PBC florid duct lesion

first line therapy for PBC

UDCA, improves cholestasis and lipid profile

safe and well tolerated

autoimmune disorder men and women

assoc with IBD

ASx AP elevation

RUQ pain, fever, jaundice

PSC [rimary sclerosing cholangitis

PSC diagnosis

endoscopic retrograde cholangiopancreatiography or MRCP

progressive inflammatory fibrosis and destruction of intra and extra hepatic bile ducts

80% have IBD

PSC

increased malignancy risk

• cholangiocarcinoma

• colon cancer

• HCC

• pancreatic cancer

PSC, colonscopy every year

PSC diagnosis

cholestatic liver profile

cholangiography

pANCA 65-80%

liver biopsy rarely diagnostic - 10% onion skin

PSC

PSC

alright

PBC and PSC AI disorders

clinical features compare

lab findings

most common causes of granulomatous liver disease

meds and sarcoidosis

granulomatous liver disease

approach to cholestatic liver enzyme elevation

history

abdominal US

AMA test

elevation of Alk Phos