93rd annual dalhousie fall refresher · •develop a practical and economical approach to evaluate...
TRANSCRIPT
![Page 1: 93rd Annual Dalhousie Fall Refresher · •Develop a practical and economical approach to evaluate abnormal serum liver tests ... •Liver function tests reflect liver synthetic function(INR,](https://reader030.vdocuments.us/reader030/viewer/2022040611/5ed8d8e56714ca7f4768adac/html5/thumbnails/1.jpg)
There is No Normal Abnormal Liver Test
Magnus McLeod MD FRCPC
Assistant Professor
Associate Program Director Internal Medicine
Dalhousie University
November 29/2019
93rd Annual Dalhousie Fall Refresher
Halifax, NS
![Page 2: 93rd Annual Dalhousie Fall Refresher · •Develop a practical and economical approach to evaluate abnormal serum liver tests ... •Liver function tests reflect liver synthetic function(INR,](https://reader030.vdocuments.us/reader030/viewer/2022040611/5ed8d8e56714ca7f4768adac/html5/thumbnails/2.jpg)
Objectives
• Develop a practical and economical approach to evaluate abnormal serum liver tests
• Demonstrate appropriate use of hepatic imaging
• Discuss the use of liver biopsy in evaluation
![Page 3: 93rd Annual Dalhousie Fall Refresher · •Develop a practical and economical approach to evaluate abnormal serum liver tests ... •Liver function tests reflect liver synthetic function(INR,](https://reader030.vdocuments.us/reader030/viewer/2022040611/5ed8d8e56714ca7f4768adac/html5/thumbnails/3.jpg)
93rd Annual Dalhousie Fall Refresher 2019Conflict Disclosures
Company/Organization Details
Advisory Board or equivalent Intercept
Gilead
Novartis
PBC/NASH
HCV/NASH
CHF
Grant(s) or an honorarium Intercept
Gilead
Lupin
PBC
HCV/NASH
IBS
Participating or participated in a clinical trial Genfit
Shire
NovoNordisk
Intercept
Gilead
NASH
NASH
NASH
NASH
NASH
PSC
![Page 4: 93rd Annual Dalhousie Fall Refresher · •Develop a practical and economical approach to evaluate abnormal serum liver tests ... •Liver function tests reflect liver synthetic function(INR,](https://reader030.vdocuments.us/reader030/viewer/2022040611/5ed8d8e56714ca7f4768adac/html5/thumbnails/4.jpg)
Definitions
• LFTs is a misnomer
• Liver enzyme abnormalities reflect injury to either hepatocytes or cholangiocytes
• Can be referred to as liver injury tests
• Liver function tests reflect liver synthetic function(INR, Bilirubin, albumin)
![Page 5: 93rd Annual Dalhousie Fall Refresher · •Develop a practical and economical approach to evaluate abnormal serum liver tests ... •Liver function tests reflect liver synthetic function(INR,](https://reader030.vdocuments.us/reader030/viewer/2022040611/5ed8d8e56714ca7f4768adac/html5/thumbnails/5.jpg)
The Common Patient
• 57 year old man with Hypertension
Obstructive Sleep Apnea
BMI 37
Dyslipidemia
HgbA1c 6%
Rare social alcohol
No symptoms
![Page 6: 93rd Annual Dalhousie Fall Refresher · •Develop a practical and economical approach to evaluate abnormal serum liver tests ... •Liver function tests reflect liver synthetic function(INR,](https://reader030.vdocuments.us/reader030/viewer/2022040611/5ed8d8e56714ca7f4768adac/html5/thumbnails/6.jpg)
Labs
• AST 39(nl <45)
• ALT 31(nl <45)
• ALP 68 (nl <150)
• Albumin 40 (nl >35)
• Total bilirubin 12 (nl <20)
• Platelets 160 (nl 150-350)
![Page 7: 93rd Annual Dalhousie Fall Refresher · •Develop a practical and economical approach to evaluate abnormal serum liver tests ... •Liver function tests reflect liver synthetic function(INR,](https://reader030.vdocuments.us/reader030/viewer/2022040611/5ed8d8e56714ca7f4768adac/html5/thumbnails/7.jpg)
Question 1
• What should be the next best step in evaluating this patient?
![Page 8: 93rd Annual Dalhousie Fall Refresher · •Develop a practical and economical approach to evaluate abnormal serum liver tests ... •Liver function tests reflect liver synthetic function(INR,](https://reader030.vdocuments.us/reader030/viewer/2022040611/5ed8d8e56714ca7f4768adac/html5/thumbnails/8.jpg)
A. Liver ultrasound and possibly Hepatology referral
B. Liver biopsy
C. Check full liver panel- ANA, Ceruloplasmin, A1AT, AMA, HBV, HCV
D. Reassurance
![Page 9: 93rd Annual Dalhousie Fall Refresher · •Develop a practical and economical approach to evaluate abnormal serum liver tests ... •Liver function tests reflect liver synthetic function(INR,](https://reader030.vdocuments.us/reader030/viewer/2022040611/5ed8d8e56714ca7f4768adac/html5/thumbnails/9.jpg)
Labs
• AST 39
• ALT 31
• ALP 68
• Albumin 40
• Total bilirubin 12
• Platelets 160
What evaluation is
indicated in this
patient?
![Page 10: 93rd Annual Dalhousie Fall Refresher · •Develop a practical and economical approach to evaluate abnormal serum liver tests ... •Liver function tests reflect liver synthetic function(INR,](https://reader030.vdocuments.us/reader030/viewer/2022040611/5ed8d8e56714ca7f4768adac/html5/thumbnails/10.jpg)
Many conditions are clinical
diagnoses
![Page 11: 93rd Annual Dalhousie Fall Refresher · •Develop a practical and economical approach to evaluate abnormal serum liver tests ... •Liver function tests reflect liver synthetic function(INR,](https://reader030.vdocuments.us/reader030/viewer/2022040611/5ed8d8e56714ca7f4768adac/html5/thumbnails/11.jpg)
![Page 12: 93rd Annual Dalhousie Fall Refresher · •Develop a practical and economical approach to evaluate abnormal serum liver tests ... •Liver function tests reflect liver synthetic function(INR,](https://reader030.vdocuments.us/reader030/viewer/2022040611/5ed8d8e56714ca7f4768adac/html5/thumbnails/12.jpg)
Directed Approach
![Page 13: 93rd Annual Dalhousie Fall Refresher · •Develop a practical and economical approach to evaluate abnormal serum liver tests ... •Liver function tests reflect liver synthetic function(INR,](https://reader030.vdocuments.us/reader030/viewer/2022040611/5ed8d8e56714ca7f4768adac/html5/thumbnails/13.jpg)
![Page 14: 93rd Annual Dalhousie Fall Refresher · •Develop a practical and economical approach to evaluate abnormal serum liver tests ... •Liver function tests reflect liver synthetic function(INR,](https://reader030.vdocuments.us/reader030/viewer/2022040611/5ed8d8e56714ca7f4768adac/html5/thumbnails/14.jpg)
![Page 15: 93rd Annual Dalhousie Fall Refresher · •Develop a practical and economical approach to evaluate abnormal serum liver tests ... •Liver function tests reflect liver synthetic function(INR,](https://reader030.vdocuments.us/reader030/viewer/2022040611/5ed8d8e56714ca7f4768adac/html5/thumbnails/15.jpg)
Back to Our Case
• AST 39
• ALT 31
• ALP 68
• Albumin 40
• Total bilirubin 12
• Platelets 160
![Page 16: 93rd Annual Dalhousie Fall Refresher · •Develop a practical and economical approach to evaluate abnormal serum liver tests ... •Liver function tests reflect liver synthetic function(INR,](https://reader030.vdocuments.us/reader030/viewer/2022040611/5ed8d8e56714ca7f4768adac/html5/thumbnails/16.jpg)
![Page 17: 93rd Annual Dalhousie Fall Refresher · •Develop a practical and economical approach to evaluate abnormal serum liver tests ... •Liver function tests reflect liver synthetic function(INR,](https://reader030.vdocuments.us/reader030/viewer/2022040611/5ed8d8e56714ca7f4768adac/html5/thumbnails/17.jpg)
![Page 18: 93rd Annual Dalhousie Fall Refresher · •Develop a practical and economical approach to evaluate abnormal serum liver tests ... •Liver function tests reflect liver synthetic function(INR,](https://reader030.vdocuments.us/reader030/viewer/2022040611/5ed8d8e56714ca7f4768adac/html5/thumbnails/18.jpg)
Further work up
• HBsAg -ve
• HBsAb -ve
• HCV -ve
• Ultrasound shows MildHepatic steatosis
![Page 19: 93rd Annual Dalhousie Fall Refresher · •Develop a practical and economical approach to evaluate abnormal serum liver tests ... •Liver function tests reflect liver synthetic function(INR,](https://reader030.vdocuments.us/reader030/viewer/2022040611/5ed8d8e56714ca7f4768adac/html5/thumbnails/19.jpg)
Prognosis
• How would you counsel this patient in regards to his prognosis?
![Page 20: 93rd Annual Dalhousie Fall Refresher · •Develop a practical and economical approach to evaluate abnormal serum liver tests ... •Liver function tests reflect liver synthetic function(INR,](https://reader030.vdocuments.us/reader030/viewer/2022040611/5ed8d8e56714ca7f4768adac/html5/thumbnails/20.jpg)
A. Low risk; refer to Hepatology when ALT>2x
ULN
B. Impossible to know prognosis without biopsy
C. High risk; Refer to Hepatology
![Page 21: 93rd Annual Dalhousie Fall Refresher · •Develop a practical and economical approach to evaluate abnormal serum liver tests ... •Liver function tests reflect liver synthetic function(INR,](https://reader030.vdocuments.us/reader030/viewer/2022040611/5ed8d8e56714ca7f4768adac/html5/thumbnails/21.jpg)
ALT
AST
ALT
AST
TIME
120
30
40
33
![Page 22: 93rd Annual Dalhousie Fall Refresher · •Develop a practical and economical approach to evaluate abnormal serum liver tests ... •Liver function tests reflect liver synthetic function(INR,](https://reader030.vdocuments.us/reader030/viewer/2022040611/5ed8d8e56714ca7f4768adac/html5/thumbnails/22.jpg)
Available Non-Invasive Tests
![Page 23: 93rd Annual Dalhousie Fall Refresher · •Develop a practical and economical approach to evaluate abnormal serum liver tests ... •Liver function tests reflect liver synthetic function(INR,](https://reader030.vdocuments.us/reader030/viewer/2022040611/5ed8d8e56714ca7f4768adac/html5/thumbnails/23.jpg)
HCV
Fibrotest
Forms Index
AST to Platelet Ratio(APRI)
Fibrospectll
MP3
Enhanced Liver Fibrosis Test(ELF)
Fibrosis Probability Index(FPI)
Hepascore
Fibrometer
Lok Index
Gotaborg University Cirrhosis Index(GUCI)
Virahep-C Model
HALT-C model
HBV
Hui score
Zeng score
HCV-HIV
FIB-4
SHASTA Index
NAFLD
NAFLD Fibrosis Index
BARD Score
![Page 24: 93rd Annual Dalhousie Fall Refresher · •Develop a practical and economical approach to evaluate abnormal serum liver tests ... •Liver function tests reflect liver synthetic function(INR,](https://reader030.vdocuments.us/reader030/viewer/2022040611/5ed8d8e56714ca7f4768adac/html5/thumbnails/24.jpg)
Transient Elastography Magnetic Resonance
Elastography
![Page 25: 93rd Annual Dalhousie Fall Refresher · •Develop a practical and economical approach to evaluate abnormal serum liver tests ... •Liver function tests reflect liver synthetic function(INR,](https://reader030.vdocuments.us/reader030/viewer/2022040611/5ed8d8e56714ca7f4768adac/html5/thumbnails/25.jpg)
NAFLD Referral
High RiskLow Risk
Fibroscan
Age
AST
ALT
Platelet count
BMI
Albumin
Impaired glucose tolerance
FIB4
NAFLD Fibrosis
Score
FIB4 EFFECT NPV/PPV%
<1.3Rules out
fibrosis95
>3.25Predicts
Fribrosis75
NFS EFFECT NPV/PPV%
<-1.455Rules out
fibrosis88-93
>0.676Predicts
Fribrosis82-90
8.5
>-1.455
>1.3
![Page 26: 93rd Annual Dalhousie Fall Refresher · •Develop a practical and economical approach to evaluate abnormal serum liver tests ... •Liver function tests reflect liver synthetic function(INR,](https://reader030.vdocuments.us/reader030/viewer/2022040611/5ed8d8e56714ca7f4768adac/html5/thumbnails/26.jpg)
Case Cont’d
Age
AST
ALT
Platelet count
BMI
Albumin
Impaired glucose tolerance
57
39
31
160
37
40
Yes
![Page 27: 93rd Annual Dalhousie Fall Refresher · •Develop a practical and economical approach to evaluate abnormal serum liver tests ... •Liver function tests reflect liver synthetic function(INR,](https://reader030.vdocuments.us/reader030/viewer/2022040611/5ed8d8e56714ca7f4768adac/html5/thumbnails/27.jpg)
Case Cont’d
Age
AST
ALT
Platelet count
BMI
Albumin
Impaired glucose tolerance
57
39
31
160
37
40
Yes
Fibroscan
![Page 28: 93rd Annual Dalhousie Fall Refresher · •Develop a practical and economical approach to evaluate abnormal serum liver tests ... •Liver function tests reflect liver synthetic function(INR,](https://reader030.vdocuments.us/reader030/viewer/2022040611/5ed8d8e56714ca7f4768adac/html5/thumbnails/28.jpg)
![Page 29: 93rd Annual Dalhousie Fall Refresher · •Develop a practical and economical approach to evaluate abnormal serum liver tests ... •Liver function tests reflect liver synthetic function(INR,](https://reader030.vdocuments.us/reader030/viewer/2022040611/5ed8d8e56714ca7f4768adac/html5/thumbnails/29.jpg)
ALT
AST
ALT
AST
TIME
120
30
40
33
8 10 12 14
![Page 30: 93rd Annual Dalhousie Fall Refresher · •Develop a practical and economical approach to evaluate abnormal serum liver tests ... •Liver function tests reflect liver synthetic function(INR,](https://reader030.vdocuments.us/reader030/viewer/2022040611/5ed8d8e56714ca7f4768adac/html5/thumbnails/30.jpg)
![Page 31: 93rd Annual Dalhousie Fall Refresher · •Develop a practical and economical approach to evaluate abnormal serum liver tests ... •Liver function tests reflect liver synthetic function(INR,](https://reader030.vdocuments.us/reader030/viewer/2022040611/5ed8d8e56714ca7f4768adac/html5/thumbnails/31.jpg)
Case Summary
• Given high Liver stiffness biopsy done
• Showed NASH cirrhosis
• EGD showed high risk varices
• HCC surveillance initiated
![Page 32: 93rd Annual Dalhousie Fall Refresher · •Develop a practical and economical approach to evaluate abnormal serum liver tests ... •Liver function tests reflect liver synthetic function(INR,](https://reader030.vdocuments.us/reader030/viewer/2022040611/5ed8d8e56714ca7f4768adac/html5/thumbnails/32.jpg)
Case 2
• 37 year old man who works in sales
• No PMHx
• No alcohol
• Has family history of diabetes
• Complains of epigastric discomfort after spicy food and coffee
• BMI 37
![Page 33: 93rd Annual Dalhousie Fall Refresher · •Develop a practical and economical approach to evaluate abnormal serum liver tests ... •Liver function tests reflect liver synthetic function(INR,](https://reader030.vdocuments.us/reader030/viewer/2022040611/5ed8d8e56714ca7f4768adac/html5/thumbnails/33.jpg)
Labs• CBC normal(platelets 280)
• Albumin 48
• Total bilirubin 10
• ALP 60
• ALT 124 (repeat 100)
• AST 101 (repeat 70)
• Normal HCV, HBV, iron indices, A1AT, ceruloplasmin, ASMA, AMA, TTG
![Page 34: 93rd Annual Dalhousie Fall Refresher · •Develop a practical and economical approach to evaluate abnormal serum liver tests ... •Liver function tests reflect liver synthetic function(INR,](https://reader030.vdocuments.us/reader030/viewer/2022040611/5ed8d8e56714ca7f4768adac/html5/thumbnails/34.jpg)
What is the next best step?
A. Reassurance
B. Check more blood work
C. Liver biopsy
D. MRCP
E. Do more extensive history
![Page 35: 93rd Annual Dalhousie Fall Refresher · •Develop a practical and economical approach to evaluate abnormal serum liver tests ... •Liver function tests reflect liver synthetic function(INR,](https://reader030.vdocuments.us/reader030/viewer/2022040611/5ed8d8e56714ca7f4768adac/html5/thumbnails/35.jpg)
A liver biopsy was performed
Referred to me
![Page 36: 93rd Annual Dalhousie Fall Refresher · •Develop a practical and economical approach to evaluate abnormal serum liver tests ... •Liver function tests reflect liver synthetic function(INR,](https://reader030.vdocuments.us/reader030/viewer/2022040611/5ed8d8e56714ca7f4768adac/html5/thumbnails/36.jpg)
Pre-Visit
• 37 year old man who works in sales
• No PMHx
• No alcohol
• Has family history of diabetes
• Complains of epigastric discomfort after spicy food and coffee
• BMI 37
![Page 37: 93rd Annual Dalhousie Fall Refresher · •Develop a practical and economical approach to evaluate abnormal serum liver tests ... •Liver function tests reflect liver synthetic function(INR,](https://reader030.vdocuments.us/reader030/viewer/2022040611/5ed8d8e56714ca7f4768adac/html5/thumbnails/37.jpg)
![Page 38: 93rd Annual Dalhousie Fall Refresher · •Develop a practical and economical approach to evaluate abnormal serum liver tests ... •Liver function tests reflect liver synthetic function(INR,](https://reader030.vdocuments.us/reader030/viewer/2022040611/5ed8d8e56714ca7f4768adac/html5/thumbnails/38.jpg)
Non-Hepatic Causes• Muscle Injury: Rhabdomyolysis, seizures, dermatomyositis, long
distance running
– Check CK level
• Thyroid disease
• Celiac Disease
• Anorexia nervosa
• Adrenal Insufficiency
• Hemolysis
![Page 39: 93rd Annual Dalhousie Fall Refresher · •Develop a practical and economical approach to evaluate abnormal serum liver tests ... •Liver function tests reflect liver synthetic function(INR,](https://reader030.vdocuments.us/reader030/viewer/2022040611/5ed8d8e56714ca7f4768adac/html5/thumbnails/39.jpg)
Case 3
• A 60 year old woman
• AST 190
• ALT 80
• ALP 300
• Bilirubin 120
• Ferritin 4500
• TS 60%
![Page 40: 93rd Annual Dalhousie Fall Refresher · •Develop a practical and economical approach to evaluate abnormal serum liver tests ... •Liver function tests reflect liver synthetic function(INR,](https://reader030.vdocuments.us/reader030/viewer/2022040611/5ed8d8e56714ca7f4768adac/html5/thumbnails/40.jpg)
Shotgun Approach Used
• HBV and HCV negative
• AMA and ASMA negative
• A1AT normal
• Ceruloplasmin normal
• Iron studies as per previous
• HFE Heterozygous C282Y/H63D
![Page 41: 93rd Annual Dalhousie Fall Refresher · •Develop a practical and economical approach to evaluate abnormal serum liver tests ... •Liver function tests reflect liver synthetic function(INR,](https://reader030.vdocuments.us/reader030/viewer/2022040611/5ed8d8e56714ca7f4768adac/html5/thumbnails/41.jpg)
What is the best therapeutic approach?
A. Needs a liver biopsy to say
B. Therapeutic phlebotomy
C. Iron chelation therapy
D. Antibiotics
E. None of the above
Hereditary Hemochromatosis
![Page 42: 93rd Annual Dalhousie Fall Refresher · •Develop a practical and economical approach to evaluate abnormal serum liver tests ... •Liver function tests reflect liver synthetic function(INR,](https://reader030.vdocuments.us/reader030/viewer/2022040611/5ed8d8e56714ca7f4768adac/html5/thumbnails/42.jpg)
Complications
• After 3rd phlebotomy had syncopal episode
• Hip fracture
• Lost to follow up
• 6 months later presented with a variceal bleed and ascites complicated by spontaneous bacterial peritonitis
![Page 43: 93rd Annual Dalhousie Fall Refresher · •Develop a practical and economical approach to evaluate abnormal serum liver tests ... •Liver function tests reflect liver synthetic function(INR,](https://reader030.vdocuments.us/reader030/viewer/2022040611/5ed8d8e56714ca7f4768adac/html5/thumbnails/43.jpg)
![Page 44: 93rd Annual Dalhousie Fall Refresher · •Develop a practical and economical approach to evaluate abnormal serum liver tests ... •Liver function tests reflect liver synthetic function(INR,](https://reader030.vdocuments.us/reader030/viewer/2022040611/5ed8d8e56714ca7f4768adac/html5/thumbnails/44.jpg)
![Page 45: 93rd Annual Dalhousie Fall Refresher · •Develop a practical and economical approach to evaluate abnormal serum liver tests ... •Liver function tests reflect liver synthetic function(INR,](https://reader030.vdocuments.us/reader030/viewer/2022040611/5ed8d8e56714ca7f4768adac/html5/thumbnails/45.jpg)
![Page 46: 93rd Annual Dalhousie Fall Refresher · •Develop a practical and economical approach to evaluate abnormal serum liver tests ... •Liver function tests reflect liver synthetic function(INR,](https://reader030.vdocuments.us/reader030/viewer/2022040611/5ed8d8e56714ca7f4768adac/html5/thumbnails/46.jpg)
Typical Labs of AH
• AST >50 but <400
• AST:ALT >1.5
• ALT <200
• Bilirubin >51
• ALP/GGT usually high
![Page 47: 93rd Annual Dalhousie Fall Refresher · •Develop a practical and economical approach to evaluate abnormal serum liver tests ... •Liver function tests reflect liver synthetic function(INR,](https://reader030.vdocuments.us/reader030/viewer/2022040611/5ed8d8e56714ca7f4768adac/html5/thumbnails/47.jpg)
Case 4
• 76 year old man
• Dark urine, jaundice, fatigue after bout of acute sinusitis
• ALT 450
• Bilirubin 180
• INR 1.3
![Page 48: 93rd Annual Dalhousie Fall Refresher · •Develop a practical and economical approach to evaluate abnormal serum liver tests ... •Liver function tests reflect liver synthetic function(INR,](https://reader030.vdocuments.us/reader030/viewer/2022040611/5ed8d8e56714ca7f4768adac/html5/thumbnails/48.jpg)
Tests
• Tested for:
• HBV, HCV, EBV, HSV, CMV, Parvovirus
• ASMA, ANA, AMA
• Ceruloplasmin, HFE gene test
• A1AT
EBV IgM positive
![Page 49: 93rd Annual Dalhousie Fall Refresher · •Develop a practical and economical approach to evaluate abnormal serum liver tests ... •Liver function tests reflect liver synthetic function(INR,](https://reader030.vdocuments.us/reader030/viewer/2022040611/5ed8d8e56714ca7f4768adac/html5/thumbnails/49.jpg)
What do you do during the next bout of sinusitis
A. Monitor liver tests closely
B. Reassure patient(EBV should not cause repeat
infxn)
C. Treat with NAC
D. Give different antibiotic than last time
![Page 50: 93rd Annual Dalhousie Fall Refresher · •Develop a practical and economical approach to evaluate abnormal serum liver tests ... •Liver function tests reflect liver synthetic function(INR,](https://reader030.vdocuments.us/reader030/viewer/2022040611/5ed8d8e56714ca7f4768adac/html5/thumbnails/50.jpg)
Drug Induced Liver Injury(DILI)
• Amoxicillin/Clavulinic acid
• Most common cause of antibiotic induced ALF
• No diagnostic test
• Will recur and should never be given again
• EBV IgM has high false positive rate
![Page 51: 93rd Annual Dalhousie Fall Refresher · •Develop a practical and economical approach to evaluate abnormal serum liver tests ... •Liver function tests reflect liver synthetic function(INR,](https://reader030.vdocuments.us/reader030/viewer/2022040611/5ed8d8e56714ca7f4768adac/html5/thumbnails/51.jpg)
Case 5
• 72 year old woman
• Fatigue, anorexia
• ALT 1200
• Bilirubin 40
• INR 1.0
CAD s/p MI
BP 110/60, HR 110
Cool legs
![Page 52: 93rd Annual Dalhousie Fall Refresher · •Develop a practical and economical approach to evaluate abnormal serum liver tests ... •Liver function tests reflect liver synthetic function(INR,](https://reader030.vdocuments.us/reader030/viewer/2022040611/5ed8d8e56714ca7f4768adac/html5/thumbnails/52.jpg)
Acute Hepatocellular Liver Injury
What needs treatment NOW
![Page 53: 93rd Annual Dalhousie Fall Refresher · •Develop a practical and economical approach to evaluate abnormal serum liver tests ... •Liver function tests reflect liver synthetic function(INR,](https://reader030.vdocuments.us/reader030/viewer/2022040611/5ed8d8e56714ca7f4768adac/html5/thumbnails/53.jpg)
Is this ALF
Tylenol? NAC
Hep B? Tenofovir
AIH Steroids
![Page 54: 93rd Annual Dalhousie Fall Refresher · •Develop a practical and economical approach to evaluate abnormal serum liver tests ... •Liver function tests reflect liver synthetic function(INR,](https://reader030.vdocuments.us/reader030/viewer/2022040611/5ed8d8e56714ca7f4768adac/html5/thumbnails/54.jpg)
![Page 55: 93rd Annual Dalhousie Fall Refresher · •Develop a practical and economical approach to evaluate abnormal serum liver tests ... •Liver function tests reflect liver synthetic function(INR,](https://reader030.vdocuments.us/reader030/viewer/2022040611/5ed8d8e56714ca7f4768adac/html5/thumbnails/55.jpg)
Testing for Inpatients with Severe Liver Injury
ALT/AST >10xULNClear History
Cardiogenic shock(cool extremities) +/-
hypotension
Ischemic
Hepatitis
Characteristic abdominal pain,
pancreatitis, feverBiliary causes
IV drug use, immunosuppression Viral hepatitis
Excessive acetaminophen, new
antibiotic or anti epileptic DILI
![Page 56: 93rd Annual Dalhousie Fall Refresher · •Develop a practical and economical approach to evaluate abnormal serum liver tests ... •Liver function tests reflect liver synthetic function(INR,](https://reader030.vdocuments.us/reader030/viewer/2022040611/5ed8d8e56714ca7f4768adac/html5/thumbnails/56.jpg)
ALT/AST >10xULNUnclear History
STEP 1
Physical exam and evaluate for cardiac
failure
Ischemic
Hepatitis
Liver U/S vs cross sectional imaging Biliary causes
HBsAg, HBV PCR, HCV Ab, HCV PCR Viral hepatitis
Drug/ingestion history, withhold meds DILI
![Page 57: 93rd Annual Dalhousie Fall Refresher · •Develop a practical and economical approach to evaluate abnormal serum liver tests ... •Liver function tests reflect liver synthetic function(INR,](https://reader030.vdocuments.us/reader030/viewer/2022040611/5ed8d8e56714ca7f4768adac/html5/thumbnails/57.jpg)
ALT/AST >10xULNUnclear History
STEP 2/3
Antismooth muscle Ab, IgG levelAutoimmune
hepatitis
Age<55, Ceruloplasmin and urine CuWilson’s
Disease
Not clear and above Liver biopsy
![Page 58: 93rd Annual Dalhousie Fall Refresher · •Develop a practical and economical approach to evaluate abnormal serum liver tests ... •Liver function tests reflect liver synthetic function(INR,](https://reader030.vdocuments.us/reader030/viewer/2022040611/5ed8d8e56714ca7f4768adac/html5/thumbnails/58.jpg)
Case 6
![Page 59: 93rd Annual Dalhousie Fall Refresher · •Develop a practical and economical approach to evaluate abnormal serum liver tests ... •Liver function tests reflect liver synthetic function(INR,](https://reader030.vdocuments.us/reader030/viewer/2022040611/5ed8d8e56714ca7f4768adac/html5/thumbnails/59.jpg)
• A 54 year old woman saw her primary care physician for an annual visit
• She complains of mild itching and fatigue
• Patient never had any surgeries and her only medications are calcium and vitamin D
• Her exam is unremarkable apart from below
![Page 60: 93rd Annual Dalhousie Fall Refresher · •Develop a practical and economical approach to evaluate abnormal serum liver tests ... •Liver function tests reflect liver synthetic function(INR,](https://reader030.vdocuments.us/reader030/viewer/2022040611/5ed8d8e56714ca7f4768adac/html5/thumbnails/60.jpg)
Labs
• Alk Phos 426
• AST 40
• ALT 54
• Total bilirubin 17
January 2017 January 2018
• Alk Phos 398
• AST 39
• ALT 58
• Total bilirubin 19
![Page 61: 93rd Annual Dalhousie Fall Refresher · •Develop a practical and economical approach to evaluate abnormal serum liver tests ... •Liver function tests reflect liver synthetic function(INR,](https://reader030.vdocuments.us/reader030/viewer/2022040611/5ed8d8e56714ca7f4768adac/html5/thumbnails/61.jpg)
![Page 62: 93rd Annual Dalhousie Fall Refresher · •Develop a practical and economical approach to evaluate abnormal serum liver tests ... •Liver function tests reflect liver synthetic function(INR,](https://reader030.vdocuments.us/reader030/viewer/2022040611/5ed8d8e56714ca7f4768adac/html5/thumbnails/62.jpg)
Elevated ALP
GGT Normal
GGT Elevated
Investigate Non-Hepatic Causes of ALP
ALP of Hepatobiliary origin
AST/ALT Elevated
![Page 63: 93rd Annual Dalhousie Fall Refresher · •Develop a practical and economical approach to evaluate abnormal serum liver tests ... •Liver function tests reflect liver synthetic function(INR,](https://reader030.vdocuments.us/reader030/viewer/2022040611/5ed8d8e56714ca7f4768adac/html5/thumbnails/63.jpg)
![Page 64: 93rd Annual Dalhousie Fall Refresher · •Develop a practical and economical approach to evaluate abnormal serum liver tests ... •Liver function tests reflect liver synthetic function(INR,](https://reader030.vdocuments.us/reader030/viewer/2022040611/5ed8d8e56714ca7f4768adac/html5/thumbnails/64.jpg)
ALP of Hepatobiliary Origin: What is the Next Best Test To Determine the
Diagnosis?
A. Liver Biopsy
B. Anti-Smooth Muscle Antibody Titre
C. Abdominal U/S
D. HIDA Scan
![Page 65: 93rd Annual Dalhousie Fall Refresher · •Develop a practical and economical approach to evaluate abnormal serum liver tests ... •Liver function tests reflect liver synthetic function(INR,](https://reader030.vdocuments.us/reader030/viewer/2022040611/5ed8d8e56714ca7f4768adac/html5/thumbnails/65.jpg)
ALP of Hepatobiliary Origin
• Next best step is Liver Ultrasound
• Differentiates Intrahepatic from Extrahepatic Cholestasis
![Page 66: 93rd Annual Dalhousie Fall Refresher · •Develop a practical and economical approach to evaluate abnormal serum liver tests ... •Liver function tests reflect liver synthetic function(INR,](https://reader030.vdocuments.us/reader030/viewer/2022040611/5ed8d8e56714ca7f4768adac/html5/thumbnails/66.jpg)
ALP of Hepatic Origin
RUQ Ultrasound
Intrahepatic Biliary Dilatation or Irregular bile ducts
Normal U/S
Intrahepatic Cholestasis
Extrahepatic Cholestasis
![Page 67: 93rd Annual Dalhousie Fall Refresher · •Develop a practical and economical approach to evaluate abnormal serum liver tests ... •Liver function tests reflect liver synthetic function(INR,](https://reader030.vdocuments.us/reader030/viewer/2022040611/5ed8d8e56714ca7f4768adac/html5/thumbnails/67.jpg)
Chronic Extrahepatic Cholestasis
![Page 68: 93rd Annual Dalhousie Fall Refresher · •Develop a practical and economical approach to evaluate abnormal serum liver tests ... •Liver function tests reflect liver synthetic function(INR,](https://reader030.vdocuments.us/reader030/viewer/2022040611/5ed8d8e56714ca7f4768adac/html5/thumbnails/68.jpg)
Chronic Intrahepatic Cholestasis
![Page 69: 93rd Annual Dalhousie Fall Refresher · •Develop a practical and economical approach to evaluate abnormal serum liver tests ... •Liver function tests reflect liver synthetic function(INR,](https://reader030.vdocuments.us/reader030/viewer/2022040611/5ed8d8e56714ca7f4768adac/html5/thumbnails/69.jpg)
Our Case Patient
• Chronic Cholestatic Liver Injury
• Normal Liver Ultrasound
• Intrahepatic Cholestasis
![Page 70: 93rd Annual Dalhousie Fall Refresher · •Develop a practical and economical approach to evaluate abnormal serum liver tests ... •Liver function tests reflect liver synthetic function(INR,](https://reader030.vdocuments.us/reader030/viewer/2022040611/5ed8d8e56714ca7f4768adac/html5/thumbnails/70.jpg)
Intrahepatic Cholestasis
Antimitochondrial Antibody(AMA)
MRCP
Liver Biopsy
Primary Biliary Cholangitis(PBC)
+-
![Page 71: 93rd Annual Dalhousie Fall Refresher · •Develop a practical and economical approach to evaluate abnormal serum liver tests ... •Liver function tests reflect liver synthetic function(INR,](https://reader030.vdocuments.us/reader030/viewer/2022040611/5ed8d8e56714ca7f4768adac/html5/thumbnails/71.jpg)
![Page 72: 93rd Annual Dalhousie Fall Refresher · •Develop a practical and economical approach to evaluate abnormal serum liver tests ... •Liver function tests reflect liver synthetic function(INR,](https://reader030.vdocuments.us/reader030/viewer/2022040611/5ed8d8e56714ca7f4768adac/html5/thumbnails/72.jpg)
Thank You
Questions?