Download Liver function test

Liver function test
Ross Stringer
• Synthetic function
• Albumin & clotting (INR/PT, APTT)
• Hepatocellular damage
• AST (aspartate aminotransferase) & ALT (alanine aminotransferase)
• Biliary dysfunction
• ALP (alkaline phosphatase) & GGT (gamma glutamyl transferase)
• Hepatic dysfunction or outflow obstruction
• Bilirubin (conjugated vs unconjugated)
System or function
Marker
Site/significance
Function
Hepatocyte integrity
AST
Liver, Heart, Muscle
Kidney, Brain, RBC,
lung, pancreas
Catabolism of
protein/aa’s
ALT
Liver
ALP
Bone, intestine, liver,
placenta
Canilicular enzyme
involved in bile prod.
GGT
Hepatobiliary injury
Transfer of GG to amino
acids
Bilirubin
Excretion disorder
Haemolysis end-product
Albumin
Diet/Liver
Hepatic synthesis
Prothrombin time
Vit K dependent factors
Bile salts aid Vit K
absorption
Cholestasis
Liver function
• Indications for LFTs
• Jaundice
• Abdominal pain; especially RUQ
• Alcohol
• Paracetamol & other drugs
• Suspected viral or AI hepatitis
• Ascites/oedema
• Confusion/delirium
• Pre-eclampsia/obstetric hypertension
• Monitoring treatment
• Etc
Interpretation in context
• Hx: abdominal pain, wt loss, fever, diet, foreign travel, IVDU, MSM, IBD,
FHx, smoking, pale stools/dark urine
• Ex: vitals, jaundice, ascites, cachexia, fever, hepatomegaly, masses
• Inx: FBC, U&E, CRP, LDH, ABG
e.g. fever, jaundice, RUQ pain in traveller returning from China
e.g. painless jaundice with RUQ mass
e.g. fever, jaundice, raised WCC/CRP, RUQ tenderness
e.g. pain following fatty meals, no fever or masses, WCC normal
e.g. diabetes, raised LFTs, skin pigmentation, joint pain, fatigue
Type of liver
injury
Liver panel
Diagnosis
Hepatitis-like
AST and ALT up to
10 ULN
AST/ALT > 2
AST/ALT > 4
Alcoholic hepatitis
Wilson’s disease
AST and ALT 10-40
ULN
ALT>AST and high Chronic viral hepatitis B or C
risk behavior
ALT>AST and no
high risk behavior
Haemochromatosis,Wilson’s disease, DILI
NAFLD, Alpha 1 antitrypsin deficiency,
Autoimmune hepatitis
AST/ALT > 1
Cirrhosis of any type
AST and ALT 40100 ULN
Acute viral hepatitis, autoimmune hepatitis
drug induced hepatitis
AST and ALT > 100
ULN
Ischemic liver injury
Paracetamol overdose
Cholestatic
ALP > 5 ULN
Gall stones/cholangitis, cholangiocarcinoma,
drug induced liver injury, PBC, PSC
Hepatitic vs cholestatic
• Hepatitic
Bilirubin 32
AST 1380
ALT 1570
ALP 230
INR 1.2
• Cholestatic
Bilirubin 340
AST 120
ALT 87
ALP 560
INR 1.4
For review at home: Abnormal LFTs is an indication for
liver screen
• Hepatitis serology (A,B/D, C, E)
• Autoantibodies (ANA, SMA, AMA, LKM)
• Iron studies (ferritin (with CRP), TIBC, transferrin)
• Alpha-1 anti-trypsin
• Copper & caeruloplasmin
• Imaging of biliary tract (USS) & liver (USS, CT)
• Liver biopsy (if indicated)
For review at home: Overview of viral hepatitis serology
Marker
Acute infection
Chronic infection
Prior infection
IgM anti-HAV

-
-
IgG anti-HAV
-
- No chronic phase

HB surface Ag


-
Anti-HB surface
-
-
 vaccination
IgM anti-HB core

-
-
IgG anti-HB core
-


Anti-HCV



HCV-RNA


-
68 female pruritis, lethargy, jaundice.
Cachexia, no signs CLD, dark urine, pale stools
Bloods
Bili 78 (3-21)
AST 35 (5-35)
ALT 39 (5-35)
ALP 156 (30-130)
GGT 176 (10-55)
Alb 39 (35-50)
Questions
1. Abnormalities?
2. Next Inx?
3. Possible causes?
68 female pruritis, lethargy, jaundice.
Cachexia, no signs CLD, dark urine, pale stools
Bloods
Bili 78
AST 35
ALT 39
ALP 156
GGT 176
Alb 39
Questions
1. Raised bili, ALP, GGT
2. USS biliary tree
3. Gallstones,
cholangiocarcinoma,
pancreatic carcinoma
47 female, ongoing tiredness, pruritis, low mood,
altered bowel habit. Hepatomegaly, xanthelasmata
Bloods
Bili 13
AST 35
ALT 34
ALP 500
GGT 30
Alb 39
Questions
1. Abnormalities?
2. Sources of ALP?
3. Further Inx?
47 female, ongoing tiredness, pruritis, low mood,
altered bowel habit. Hepatomegaly, xanthelasmata
Bloods
Bili 13
AST 35
ALT 34
ALP 500
GGT 30
Alb 39
Questions
1. ALP raised
2. Biliary tree, bone, placenta
3. Liver screen
1. Esp. autoantibodies
2. Liver biopsy
PBC, PSC
34 male. RUQ pain, fever, sweats. Returning
traveller. Tender RUQ, spiking temperatures.
Bloods
Bili 51
AST 46
ALT 76
ALP 10
GGT 87
Alb 42
CRP 142
Questions
1. Abnormalities?
2. Further Inx?
3. Diagnosis?
34 male. RUQ pain, fever, sweats. Returning
traveller. Tender RUQ, spiking temperatures.
Bloods
Bili 51
AST 46
ALT 76
ALP 10
GGT 87
Alb 42
CRP 142
Questions
1. Bili, transaminases
2. USS
3. Liver abscess, cholangitis
32 male. Abnormal blood test at occupational
health. Recent operation overseas. Non-drinker.
Bloods
Bili 11
AST 350
ALT 400
ALP 45
GGT 57
Alb 39
Questions
1. Pattern of LFTs?
2. Further tests?
3. Possible diagnoses?
32 male. Abnormal blood test at occupational
health. Recent operation overseas. Non-drinker.
Bloods
Bili 11
AST 350
ALT 400
ALP 45
GGT 57
Alb 39
Questions
1. ALT>AST & raised, GGT slightly
raised
2. Liver screen; esp viral hep
serology
3. Likely chronic viral hepatitis (B
or C)