Liver dance: The steps in diagnosis of abnormal liver tests

LiverDance:
The Steps in Diagnosis of
Abnormal Liver Tests
Patricia L. Raymond MD FACG
Rx For Sanity

LiverDance

Pretest
• What are “Liver Function Tests” verses
“Liver Tests”?

• What does SGOT/SGPT ratio tell you about
the etiology of the liver damage?

• What about AP out of proportion to TA
elevation?

• Do you know how to calculate discriminant
function? What do you do with it?
LiverDance

What we’ll cover today…
 Interpreting
liver tests
 Alphabet soup
© 2010 Patricia Raymond www.RxForSanity.com 888/437-7286
www.YourHealthChoice.net 888- 4 Dr Pat 6

Some specific diseases
www.ColonJoke.com

 What we won’t cover: Treatment

LiverDance

The Dance of the Liver Tests
 Determine “Style” based on labs
 Directed History
 Directed Physical www.YourHealthChoice.net
www.ColonJoke.com
888- 4 Dr Pat 6

 More Labs
 Imaging studies or biopsy

LiverDance

First Step:
Hepatitic or Cholestatic?
 Hepatitic  Cholestatic
 Viral  Primary Biliary Cirrhosis
 Alcoholic (PBC)
 NASH  Primary Sclerosing
 Autoimmune Cholangitis (PSC)
 Structural Obstruction
 Hemochromatosis
 Drug Induced
 Alpha-1 Antitrypsin
 Wilson’s Disease
 Drug Induced

LiverDance

Hepatitic or Cholestatic:
How Do You Know?
 Hepatitic  Cholestatic
 SGOT/AST  Alkaline
 SGPT/ALT Phosphatase
(ALP)
 GGTP
•If liver tests 3-5x normal,
“most likely”; exceptions
 5’ Nucleotidase
occur

LiverDance

Do Not Use the Term “Liver
Function Tests” (LFTs)
 Albumin
 Cholesterol
 Bilirubin www.YourHealthChoice.net
www.ColonJoke.com
888- 4 Dr Pat 6

 Prothrombin time
 Low platelet count in correct setting is
suggestive of portal hypertension

LiverDance

Second Step:
History Appropriate to Lab Style
Hepatitic Lab Values
 Viral Hepatitis: Transfusions, tattoos,
IVDA, multiple sexual partners (>6/yr
© 2010 Patricia Raymond www.RxForSanity.com
www.YourHealthChoice.net
www.ColonJoke.com
888/437-7286
888- 4 Dr Pat 6

considered high risk), travel, work in day
care or preschool, homosexuality
 Alcohol Induced: Precise ethanol intake

 NASH: Diabetes, hyperlipidemia

LiverDance

www.ColonJoke.com

LiverDance

Second Step:
Hepatitic Lab Values
 Autoimmune: Amenorrhea, diabetes, thyroid
disease, vitiligo, arthritis

 Hemochromatosis: FHx, diabetes, arthritis,
www.ColonJoke.com
888- 4 Dr Pat 6

impotence, FHx “early MI”
 A1AT: FHx, neonatal jaundice
 Wilson’s: FHx, personality changes, bone
wasting, Fanconi’s syndrome, hemolytic anemia
 Drug Induced: Careful drug history

LiverDance

Second Step:
Cholestatic
 PBC: Itching, Worse at noc and on palms/soles,
FHx connective tissue disease, Raynaud’s,
sicca, GERD, xanthelasma www.ColonJoke.com

 PSC: Itching, Sx of IBD (Ulcerative Colitis)

 Structural: Hx biliary surgery, abdominal
pain/fever, acholic stool
 Drug Induced: Careful drug history

LiverDance

“I just drink one beer a day.”

LiverDance

Step Three:
Let’s Get Physical
 Liver size and consistancy, palpable
spleen or gallbladder
 Spider nevi, palmar erythema, gynecomastia, caput
medusaePatricia Raymond
© 2010 www.RxForSanity.com 888/437-7286
 Dupuytren's contractures, parotid gland enlargement,
www.ColonJoke.com
888- 4 Dr Pat 6

and testicular atrophy
 An enlarged left supraclavicular node (Virchow's node)
or periumbilical nodule (Sister Mary Joseph's nodule)
 Assessment for ascites
 Xanthelasmas
 Kaiser-Fleisher Rings

LiverDance

Step Four:
Let’s order more labs
Hepatitic:
 Hepatitis profile (incl HBsAb, HBsAg,
HBcAb), HCV Ab, Fe, TIBC
www.ColonJoke.com
888/437-7286
888- 4 Dr Pat 6

 Second round: ANA, ceruloplasmin, AIAT
phenotype, AFP
Cholestatic:
 AMA, ANA, early ultrasound to image liver

LiverDance

Just Say NO
to CAT scans in liver pathology

www.ColonJoke.com

LiverDance

A Word on Imaging Studies:
 Ultrasound RUQ
 Economical
 Liver texture, bile duct diameter, stones, ascites, liver/
size, masseswww.RxForSanity.com
spleenPatricia Raymond
© 2010
888/437-7286
888- 4 Dr Pat 6
www.ColonJoke.com
 Best for HCC screening
 CT- masses, not too good for bile duct
 ERCP/MRCP- best image of biliary tree
 Liver/Spleen scan
 Defines coloid shift, size- not too useful

LiverDance

Step Five (Last):
The Liver Biopsy
 Invasive technique with significant
complications
 Gold standard in liver diagnosis
888/437-7286
888- 4 Dr Pat 6

 Unclear etiology despite tests
www.ColonJoke.com

 Exclude other dx prior to rx with significant SE
 Obtain tissue for diagnosis (Fe, Cu,
neoplasm)
 Obtain tissue for “staging” (HCV, NASH)

LiverDance

Side Step: Discriminant function
 (4.6 * Δ PT) + bili

 If >32, 50% mortality in 1 month
www.ColonJoke.com
888- 4 Dr Pat 6

 Prednisone 40 mg/day for 20-40 days

LiverDance

Baby Steps: Learn the Liver Dance
 Determine “Style”
based on labs
 Directed History
 Directed Physical
 More Labs
 Imaging studies or
biopsy

LiverDance

Case History #1
 35 y/o male, malaise
 SGOT 1200 SGPT 3000 T Bil 3.2 AP 120
 Drinks “moderately” daily www.YourHealthChoice.net
www.ColonJoke.com
888- 4 Dr Pat 6

 Theraflu ingestion plus tylenol for flu
 What do you do now?

LiverDance

Case History #2
 70 y/o female, assymptomatic
 SGOT 56 SGPT 74 AP 357 T Bil 2.1
 Nocturnal pruritis www.YourHealthChoice.net
www.ColonJoke.com
888- 4 Dr Pat 6

LiverDance

Case History #3
 56 y/o male, executive, assymptomatic
 SGOT 70 SGPT 85
 Modest EToH (Social) www.YourHealthChoice.net
www.ColonJoke.com
888- 4 Dr Pat 6

 Extensive tattoos in past

LiverDance

Case History #4
 80 y/o female, painless jaundice
 SGOT 200 SGPT 350 AP 300 T Bil 12
 Weight loss, acholic stools www.YourHealthChoice.net
www.ColonJoke.com
888- 4 Dr Pat 6

LiverDance

Case History #5
 48 y/o female, assymptomatic
 SGOT 55 SGPT 47 AP nl T Bil nl
 Mild obesity www.YourHealthChoice.net
www.ColonJoke.com
888- 4 Dr Pat 6

LiverDance

Case History #6
 35 y/o male, assymptomatic
 SGOT 55 SGPT 45 AP nl T Bil nl
 Moderate alcohol intake www.YourHealthChoice.net
www.ColonJoke.com
888- 4 Dr Pat 6

 Premature MI in relatives

LiverDance

Stuff to put on your reading list:
 Clinical presentation of autoimmune hepatitis
and appropriate management
 Indications for treatment of chronic hepatitis C

 Clinical presentation and management Gilbert’s
www.ColonJoke.com
888- 4 Dr Pat 6

syndrome
 Some medications that may cause abnormal
liver tests
 Clinical presentation and diagnostic approach to
Budd-Chiari syndrome

LiverDance

Alphabet Soup

LiverDance

Hepatitis A
 Enteric
 HAV vaccination in :
 Military personnel· Food handlers· Injection drug
users, Patricia Raymond
© 2010 Travellers to endemic regions (essentially
www.RxForSanity.com
888/437-7286
888- 4 Dr Pat 6
anywhere outside ofwww.ColonJoke.com
North America, Western Europe
and Japan)
 Occupational risk including healthcare workers,
employees of mental health facilities and sewage
workers, consumers of high-risk foods (e.g. raw
shellfish)
 Patients with chronic liver disease - especially chronic
hepatitis C - increased risk for fulminant hepatitis or
death with HAV superinfection.
LiverDance

Hepatitis A
 Most HAV infections acquired in childhood are
subclinical and anicteric, yet antibodies to the virus
persist for life and provide immunity to further infection.
 In adults, Patricia Raymond
© 2010
75 to 95% of www.RxForSanity.com are symptomatic, with
infections 888/437-7286
jaundice in the majoritywww.YourHealthChoice.net
of cases. Fulminant 888- 4 Dr Pat 6
hepatic
failure is rare but increases over the age of 40, and
www.ColonJoke.com

possibly in the context of underlying chronic liver
disease.
 In some individuals, HAV causes a biphasic illness with a
second bout of jaundice and cholestasis six to 12 weeks
after the primary infection.
 Chronic HAV infection does not occur and liver enzymes
are almost always normal within six months of infection.

LiverDance

Hepatitis B
 Antigens
HBsAg = presence of the virus
HBcAg = not detected in blood
HBeAg = correlates with the viral replication and
infectivity
www.ColonJoke.com

 Antibodies
anti-HBs = antibodies to the surface
anti-HBc = antibodies to the core can be either IgM
(acute) or IgG (chronic)
anti-HBe = antibodies to e and indicates low infectivity
and probable recovery


LiverDance

Hepatitis B
Extra-Hepatic Associations :associated with hepatitis B
antigen/antibody complexes.

Polyarteritis - usually involves medium and small arteries, appears
early
www.ColonJoke.com
Glomerulonephritis - largely in children, liver disease is usually mild

Polymyalgia rheumatica - usually in older persons

Essential mixed cryoglobulinemia - sometimes only a test tube
finding

Guillain-Barre syndrome

Myocarditis LiverDance

Hepatitis C: Acute
 Very mild and often not clinically apparent.
 Less than 15% of all cases of acute hepatitis in
the USA.
 Only 2010 Patricia Raymond 25% of persons are jaundiced. 888/437-72866
© about 15 - www.RxForSanity.com
www.YourHealthChoice.net 888- 4 Dr Pat
 Antibodies to hepatitis C may takewww.ColonJoke.comup to three months to detect .
 Early diagnosis may be difficult.
 About 20% of persons with acute hepatitis C
fully recover and are felt to clear the virus
 80% develop some form of chronicity.
 Twenty-five percent of patients with chronic hepatitis will develop
cirrhosis after 20 years
 Of these, 5% will develop liver cell cancer and 5%
decompensated cirrhosis.
LiverDance

Hepatitis C
 Chronic hepatitis C infection causes chronic immune
stimulation and autoimmune diseases are more frequent
in hepatitis C.
 AutoimmuneRaymond
© 2010 Patricia
diseases may be seen either as presenting
www.RxForSanity.com 888/437-7286
conditions or in association with hepatitis C.888- 4 Dr Pat 6
www.ColonJoke.com

 Diabetes Mixed cryoglobulinemia Thyroiditis
Erythema nodosum Erythema multiforme Glomerulonephritis
Hypothyroidism Lichen planus Polyarteritis
Urticaria Porphyria cutanea tarda Polymyalgia
B-cell lymphoma Mooren corneal ulcers

LiverDance

Hepatitis D
 Unique incomplete virus
 Requires hepatitis B virus (HBV) for its
replication
 The©RNA genome is covered by an outer coat of 888/437-72866 B
2010 Patricia Raymond www.RxForSanity.com
hepatitis
888- 4 Dr Pat
surface antigen. www.ColonJoke.com

 Endemic in certain regions including the
Mediterranean basin, the Balkan peninsula, the
former Soviet Union, parts of Africa and the
Middle East and the Amazon basin of South
America.
 Spread is intrafamilial and through sexual
contact.
LiverDance

Hepatitis D: Clinical Course
 Depends on whether the virus was
acquired as
 a coinfection with hepatitis B
 in acute self-limited hepatitis although fulminant hepatitis and
www.ColonJoke.com
888- 4 Dr Pat 6

death are well described.
 a superinfection in an individual with a
previously established chronic HBV infection.
 typical course is one of a rapidly progressive chronic
hepatitis.

LiverDance

Hepatitis E
 Self-limited acute form of viral hepatitis that is typically
spread by fecally contaminated water.

 Endemic Patriciadeveloping www.RxForSanity.com
© 2010 in Raymond countries 888/437-7286
 The most common cause of acute viral hepatitis worldwide, it is
www.ColonJoke.com
888- 4 Dr Pat 6

virtually unheard of in North America. Rare cases have been
described in travellers returning from endemic regions.
 The clinical hallmark of HEV infection is its extremely
high mortality rate when infection occurs in pregnancy,
particularly in the third trimester.
 No HEV vaccine is yet available.

LiverDance

Medication
 Almost any medication can cause an elevation
of liver enzymes.
 Common ones include nonsteroidal anti-
inflammatory drugs, antibiotics, HMG-CoA
www.ColonJoke.com

reductase inhibitors, antiepileptic drugs, and
antituberculous drugs.
 In addition to prescription medications, herbal
preparations and illicit drug use may also be the
cause.

LiverDance

Herbs are safe…not
 Comfry
 Germander
 Pennyroyal
888/437-7286
888- 4 Dr Pat 6
www.ColonJoke.com
 Mistletoe
 Kava
 Chapparal
 Ma-Huang
 Ephedra, Senna, Cascara

LiverDance

NASH Epidemic
 Risk factors: central obesity, type 2 diabetes
mellitus, dyslipidemia, and metabolic syndrome
 20 to 40 % of the general population

 Symptoms: most asymptomatic, rare fatigue,
www.ColonJoke.com

malaise, and vague right upper abdominal
discomfort
 Dx: fat in liver (US), < 20 g alcohol daily,
negative hepatitis B & C serology

LiverDance

The liver takes a beating

www.ColonJoke.com

LiverDance

NASH Epidemic
 AST and ALT elevated in 90 %
 AST/ALT ratio is less than 1
 Much lower than thewww.RxForSanity.com
© 2010 Patricia Raymond
ratio in alcoholic hepatitis
888/437-7286
 Usually > 2 www.ColonJoke.com

 Treatment: Weight loss

LiverDance

Wilsons Disease

www.ColonJoke.com

LiverDance

Wilson’s Disease
 Autosomal recessive defect of cellular copper
export
 Accumulation of copper, initially in the liver and then

in other tissues, particularly the brain. 888- 4 Dr Pat 6
www.ColonJoke.com

 Hepatic, neurologic, hematologic, and renal

impairment.
 Kayser-Fleischer rings in 50 to 60 % with isolated
hepatic involvement, > 90 % with neurologic involvement
 Ceruloplasmin concentration < 20 mg/dL with Kayser-
Fleischer rings is considered to be diagnostic.

LiverDance

Liver dance: The steps in diagnosis of abnormal liver tests

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