Term
| What is the period of time that you must see elevated liver enzymes in the presence of active liver injury for it to be considered "chronic"? |
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Definition
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Term
What clinical pattern of liver disease is described by each of the following?
1) ALP >400, high bilirubin and AST/ALT of 50
2) AST and ALT >200 with ALP of 240 |
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Definition
1) Cholestatic disease (gall stone, malignant obstruction, primary biliary cirrhosis, drug-induced). High ALP and bilirubin, with mild increase in ALT/AST is characteristic
2) Hepatocellular (viral hepatitis; alcoholic liver disease)
- >5x normal transaminase levels of 40
- ALP between 2-3X normal (28-126) |
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Term
| What are the typical LFT enzymes measured and why can they be misleading? |
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Definition
May be abnormal in healthy liver and may reflect health of liver but not function.
1) ALT (liver cytosol, so liver-specific)
2) AST (found in many places)
3) ALP (4 genes)- if ALP>> but GGT is normal, most likely a bone issue and not liver.
4) GGT (hepatocytes and biliary epithelial cells)- sensitive but NOT specific
Albumin and PT test liver SYNTHETIC function |
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Term
| How can GGT levels be most useful in assessing hepatic disease? |
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Definition
1) Elevated ALP
- If GGT is normal, it is from bone and not from liver
2) Suspicious of alcohol use
- AST:ALT ratio >2:1 |
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Term
Patients LFTs come back and reveals ALP of 400, AST and ALT of 48 and 52, and a high bilirubin.
How do you proceed with working this patient up? |
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Definition
This is a cholestatic pattern, so you want to determine whether the etiology is intrahepatic cholestasis or extrahepatic cholestasis.
1) Order upper right ultrasound to look for biliary dilation (Extrahepatic).
2) If biliary dilation is seen, you may also need a CT of abdomen or ERCP (diagnositic and treatment)
- common causes of extraheptic cholestasis are malignancy, PSC (IBD), chronic pancreatitis and AIDS cholangiophaty.
3) If dilation is not seen on US, think Drug-induced cholestasis, Primary biliary cirrhosis (PBC) or PSC |
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Term
| How are Bilirubin levels assessed? |
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Definition
Separate water soluble (direct) conjugated bilirubin from lipid soluble (indirect) unconjugated bilirubin.
Direct bilirubin (conjugated to urobilirubin by bacteria in intestine) is secreted in urine and bile, while Indirect bilirubin is bound to albumin and no excreted. |
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Term
| What are major tests of Hepatic synthetic function? |
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Definition
1) Serum albumin
- 20 d half life so NOT ACUTE MEASURE
2) PT time
- liver synthesizes coagulation factors, and PTT evaluates extrinsic coagulation pathway (<50% of normal is needed to prolong PTT) |
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Term
When might each of the following markers be useful to diagnose liver pathology?
1) Serum Ammonia
2) Serum alpha-fetoprotein
3) LDH
4) 5' nucleotidase |
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Definition
1) Excretory function of protein metabolism
2) Elevated in Hepatocellular carcinoma
3) Elevated in liver disease, cancer and hemolysis
4) Liver isoform released into bloodstream. |
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Term
When might you use each of the following Imaging techniques to diagnose/treat liver disease?
1) Ultrasound
2) CT
3) Technetium-99 radioisotope
4) HIDA scan
5) PTC
6) ERCP |
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Definition
1) Real-time and cheap for screening purposes (bone and bowel gas is a problem).
2) Radiation exposure but good detection
3) Taken up by kupffer cells, so it shows when they are replaced.
4) Nuclear medicine test for bile flow and gallbladder function
5) Biliary tree and identification of obstructive cholestasis (interventional capabilities, but radiation and discomfort
6) Therapeutic capabilities without needle in liver like PTC |
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Term
| What are the 7 major types of liver pathology? |
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Definition
1) Viral hepatitis
2) Cholestatic liver disease
- PSC, PBC, gallstones, TPN and liver
3) Drug-induced
- direct toxic (predictable, dose-dependent)
- idiosyncratic (unpredictable and not dose-dependent)
4) Genetic and Metabolic
5) Vascular
6) Tumors (benign, hepatocellular carcinoma and metastatic disease)
7) Infections and granulomatous disorders |
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Term
| Describe the basics of acetaminophen (APAP) liver toxicity. |
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Definition
Patient presents with nausea, vomiting, fatique, jandic and RUQ pain.
1) Acetaminophen metabolism requires glutathione
2) When glutathione is depleted upon massive ingestion of aspirin, NAPQ1 builds up and causes hepatic necrosis |
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Term
Patient presents with nausea, vomiting, fatique, jandic and RUQ pain.
AST/ALT are 15,000 and ALP is mildly elevated.
What do you think it happening and how do you treat? |
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Definition
Acetaminophen (APAP) toxicity and hepatic necrosis.
Treat with N-acetylcystein to replenish glutathione.
If this fails, do liver transport. |
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Term
| What are the common symptoms/signs of liver disease? |
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Definition
1) Symptoms
- Jaundice
- Fatigue
- Itching (pruritus)
- RUQ pain
- Abdominal distention
- GI bleed
2) Signs
- Icterus
- Hepatomegaly
- Splenomegaly
- Spider angiomatoa
- Palmar erythema
- Males with cirrhosis get gynecomastia.
If advanced, you may see ascites, peripheral edema, muscle wasting, and portal hypertension. |
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Term
| What is cirrhosis and how is it staged? |
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Definition
Fibrous septa that diffusely involve the liver and separate it into nodules
Child-Turcott-Pugh Score
1) Child's A- 5-6 (mild)
2) Child's B- 7-9 (moderate)
3) Child's C- 10-15 (severe)
Based on Encephalopathy, Ascites, Bilirubin, Cholestatic disease, INR, Albumin, each of which is scored 1-3 |
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