Abnormal LFT's

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Information about Abnormal LFT's

Published on April 1, 2008

Author: hanash

Source: slideshare.net

Description

causes and interpreitations of abnormal liver function tests

Abnormal LFT’s Dr E M Said

why do we check LFT’s? Well person screening To investigate unexplained symptoms For pre-operative or base line assessment For investigation of suspected liver disease

Well person screening

To investigate unexplained symptoms

For pre-operative or base line assessment

For investigation of suspected liver disease

What are LFT’s? The term “LFTs” is imprecise… Many of the tests reflecting the health of the liver are not direct measure if its function . Normal test values are arbitrarily defined as those occurring within two standard deviation of the the mean i.e 5% of of healthy individuals will have abnormal LFTs

The term “LFTs” is imprecise…

Many of the tests reflecting the health of the liver are not direct measure if its function .

Normal test values are arbitrarily defined as those occurring within two standard deviation of the the mean i.e 5% of of healthy individuals will have abnormal LFTs

According to the American Gastroenterological Association (AGA), 1 to 4 percent of the asymptomatic population may have elevated serum liver chemistries. This is consistent with the usual definition .

According to the American Gastroenterological Association (AGA), 1 to 4 percent of the asymptomatic population may have elevated serum liver chemistries.

This is consistent with the usual definition .

Remember…. abnormal LFTs often,but not always,indicate something wrong with the liver. The commonly used LFTs may be abnormal even in a healthy liver. Normal LFTs do not always mean that the liver is normal.

abnormal LFTs often,but not always,indicate something wrong with the liver.

The commonly used LFTs may be abnormal even in a healthy liver.

Normal LFTs do not always mean that the liver is normal.

approach History: The most important part in evaluation of a patient with abnormal LFTs

History:

The most important part in evaluation of a patient with abnormal LFTs

approach History: The most important part in evaluation of a patient with abnormal LFTs Exposure to any chemicals Use of any medications The duration of abnormal LFTs The presence of accompanying symptoms e.g jaundice ,artheralgia,Wt loss fever,pruritus

History:

The most important part in evaluation of a patient with abnormal LFTs

Exposure to any chemicals

Use of any medications

The duration of abnormal LFTs

The presence of accompanying symptoms e.g jaundice ,artheralgia,Wt loss fever,pruritus

approach History: The most important part in evaluation of a patient with abnormal LFTs Physical examination: ?finding suggestive CLD

History:

The most important part in evaluation of a patient with abnormal LFTs

Physical examination:

?finding suggestive CLD

approach History: The most important part in evaluation of a patient with abnormal LFTs Physical examination: ?finding suggestive CLD

History:

The most important part in evaluation of a patient with abnormal LFTs

Physical examination:

?finding suggestive CLD

approach History: The most important part in evaluation of a patient with abnormal LFTs Physical examination: ?finding suggestive CLD Lap testing: evaluate the overall pattern

History:

The most important part in evaluation of a patient with abnormal LFTs

Physical examination:

?finding suggestive CLD

Lap testing:

evaluate the overall pattern

LFT profile : Bilirubin Total protein ALT ALP Gamma GT Albumin Prothrombin time

Bilirubin

Total protein

ALT

ALP

Gamma GT

Albumin

Prothrombin time

Patterns of abnormal LFT’s Sole or combined elevation acute or chronic Predominantly Hepatocellular Predominantly cholestatic

Sole or combined elevation

acute or chronic

Predominantly Hepatocellular

Predominantly cholestatic

Bilirubin Produced by haemoglobin catabolism Isolated hyper bilirubinaemia occurs in tow settings: Over production Impaired uptake,conjugation or excretion

Produced by haemoglobin catabolism

Isolated hyper bilirubinaemia occurs in tow settings:

Over production

Impaired uptake,conjugation or excretion

 

ALT cytoplasmic enzyme that is predominantly hepatic in origin Lesser quantities are found in the kidneys, heart, and skeletal muscle Injury or disease of the liver parenchyma cause a release of the enzyme into the bloodstream Generally, most ALT elevations are caused by liver dysfunction

cytoplasmic enzyme that is predominantly hepatic in origin

Lesser quantities are found in the kidneys, heart, and skeletal muscle

Injury or disease of the liver parenchyma cause a release of the enzyme into the bloodstream

Generally, most ALT elevations are caused by liver dysfunction

Typical ALT Values in Disease

 

ALP Largely originate from the liver,mainly cells lining biliary ducts or membranes adjoining the bile canaliculi,and bones Marked increase is typical of cholestasis (often with raised GGT) Variety of bone disorders (usually without raised GGT) Isoenzymes may be useful for distinguishing these sources

Largely originate from the liver,mainly cells lining biliary ducts or membranes adjoining the bile canaliculi,and bones

Marked increase is typical of cholestasis (often with raised GGT)

Variety of bone disorders (usually without raised GGT)

Isoenzymes may be useful for distinguishing these sources

 

 

Gamma GT Found in the hepatocytes and biliary epithelial cells. Sensitive in detecting hepatobiliary disease but limited by lack of specificity Best used to evaluate elevation of other enzymes High GGT with otherwise normal liver should not lead to exhaustive work up for liver disease

Found in the hepatocytes and biliary epithelial cells.

Sensitive in detecting hepatobiliary disease but limited by lack of specificity

Best used to evaluate elevation of other enzymes

High GGT with otherwise normal liver should not lead to exhaustive work up for liver disease

Gamma GT Found in the hepatocytes and biliary epithelial cells. Sensitive in detecting hepatobiliary disease but limited by lack of specificity Best used to evaluate elevation of other enzymes High GGT with otherwise normal liver should not lead to exhaustive work up for liver disease Twofold elevation with AST:ALT ratio2:1suggest alcohol abuse

Found in the hepatocytes and biliary epithelial cells.

Sensitive in detecting hepatobiliary disease but limited by lack of specificity

Best used to evaluate elevation of other enzymes

High GGT with otherwise normal liver should not lead to exhaustive work up for liver disease

 

Albumin Albumin is synthesised in the liver Albumin has a plasma half-life of three weeks; therefore, serum albumin concentrations change slowly in response to alterations in synthesis. In practice, patients with low serum albumin concentrations and no other LFT abnormalities are likely to have a nonhepatic cause for low albumin, such as proteinuria or an acute or chronic inflammatory state.

Albumin is synthesised in the liver

Albumin has a plasma half-life of three weeks; therefore, serum albumin concentrations change slowly in response to alterations in synthesis.

In practice, patients with low serum albumin concentrations and no other LFT abnormalities are likely to have a nonhepatic cause for low albumin, such as proteinuria or an acute or chronic inflammatory state.

Prothrombin time Not usually included in the LFTs panel abnormal PT prolongation may be a sign of serious liver dysfunction. An elevated PT can result from a vitamin K deficiency ,a trial of vitamin K injections is the most practical way to exclude vitamin K deficiency in such patients.

Not usually included in the LFTs panel

abnormal PT prolongation may be a sign of serious liver dysfunction.

An elevated PT can result from a vitamin K deficiency ,a trial of vitamin K injections is the most practical way to exclude vitamin K deficiency in such patients.

Predominantly Hepatocellular Usually ALT>ALP Alcoholic hepatitis

Usually ALT>ALP

Alcoholic hepatitis

Predominantly Hepatocellular Usually ALT>ALP Alcoholic hepatitis Typically AST:ALT is 2:1 AST rarely exceed300

Usually ALT>ALP

Alcoholic hepatitis

Typically AST:ALT is 2:1

AST rarely exceed300

Predominantly Hepatocellular Usually ALT>ALP Alcoholic hepatitis Viral hepatitis

Usually ALT>ALP

Alcoholic hepatitis

Viral hepatitis

Predominantly Hepatocellular Usually ALT>ALP Alcoholic hepatitis Viral hepatitis Aminotransferase>500 ALT greater or equal AST

Usually ALT>ALP

Alcoholic hepatitis

Viral hepatitis

Predominantly Hepatocellular Usually ALT>ALP Alcoholic hepatitis Viral hepatitis Toxic hepatitis Shock liver(ischemic hepatitis)

Usually ALT>ALP

Alcoholic hepatitis

Viral hepatitis

Toxic hepatitis

Shock liver(ischemic hepatitis)

Predominantly Hepatocellular Usually ALT>ALP Alcoholic hepatitis Viral hepatitis Toxic hepatitis Shock liver(ischemic hepatitis) exceeding1000IU/L Or 50x upper limit of normal

Usually ALT>ALP

Alcoholic hepatitis

Viral hepatitis

Toxic hepatitis

Shock liver(ischemic hepatitis)

Predominantly Hepatocellular Usually ALT>ALP Alcoholic hepatitis Viral hepatitis Toxic hepatitis Shock liver(ischemic hepatitis) Wilson disease Autoimmune hepatitis

Usually ALT>ALP

Alcoholic hepatitis

Viral hepatitis

Toxic hepatitis

Shock liver(ischemic hepatitis)

Wilson disease

Autoimmune hepatitis

Copyright ©2003 BMJ Publishing Group Ltd. Limdi, J K et al. Postgrad Med J 2003;79:307-312 Suggested algorithm for evaluating raised transaminases

Predominantly cholestatic Usually ALP>ALT 1 st determine intra or extrahepatic Distinction may not be straightforward 1 st step is Ultrasound biliary dilatation extrahepatic cholestasis no dilatation intrahepatic cholestasis False negative in partial obstruction,cirrhosis or PSC

Usually ALP>ALT

1 st determine intra or extrahepatic

Distinction may not be straightforward

1 st step is Ultrasound

biliary dilatation extrahepatic cholestasis

no dilatation intrahepatic cholestasis

False negative in partial obstruction,cirrhosis or PSC

extrahepatic cholestasis Choledocholithiasis Malignant causes: Pancreatic,gall bladder,ampullary and cholangiocarcinoma Hilar lymphadenopathy Chronic pancreatitis AIDS cholangiopathy

Choledocholithiasis

Malignant causes:

Pancreatic,gall bladder,ampullary and cholangiocarcinoma

Hilar lymphadenopathy

Chronic pancreatitis

AIDS cholangiopathy

intrahepatic cholestasis Drug induced Primary biliary cirrhosis Primary sclerosing cholangitis Other causes include: Sepsis,postoperative,paraneoplastic, thyroid cancer,Hypernephroma & prostate cancer

Drug induced

Primary biliary cirrhosis

Primary sclerosing cholangitis

Other causes include:

Sepsis,postoperative,paraneoplastic,

thyroid cancer,Hypernephroma & prostate cancer

Copyright ©2003 BMJ Publishing Group Ltd. Limdi, J K et al. Postgrad Med J 2003;79:307-312 Suggested algorithm for evaluating a raised ALP

The role of liver biopsy Most patients with abnormal LFTs with suspected etiologic factors for liver disease are identified by history taking, physical examination, further blood tests, and imaging In patients with unexplained LFTs elevations, a liver biopsy may be helpful to identify the cause of liver disease The decision to perform a liver biopsy must balance the possible risks of the procedure (eg, discomfort, bleeding, peritonitis, pneumothorax) with the potential benefits

Most patients with abnormal LFTs with suspected etiologic factors for liver disease are identified by history taking, physical examination, further blood tests, and imaging

In patients with unexplained LFTs elevations, a liver biopsy may be helpful to identify the cause of liver disease

The decision to perform a liver biopsy must balance the possible risks of the procedure (eg, discomfort, bleeding, peritonitis, pneumothorax) with the potential benefits

 

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