ANOOP'S LFT
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Transcript of ANOOP'S LFT
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LIVER FUNCTION TESTS
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Some example of liver dysfunction
Hepatocellular disease Cholestastic disease
Cirrhosis of the liver
Hepatitis Jaundice
Liver cancer
Fatty Liver
Genetic Disorders
Hemochromatosis (iron storage)
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LFT :TB 4 mg/dl [0.3-1 mg/dl] DB 1 mg/dl [0.1-0.3 mg/dl]
AST 250 U/L [0-35 U/L] ALT 220 U/L [0-35 U/L]
ALP 100 U/L [30-120 U/L]
Case 112/F Presented With RUQ Pain ,
Icterus
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LFT :TB 2 mg/dl [0.3-1 mg/dl] DB 1.5 mg/dl [0.1-0.3 mg/dl]
AST 1000 U/L [0-35 U/L] ALT 1300 U/L [0-35 U/L]
ALP 180 U/L [30-120 U/L]
U/S : bile duct dilatation with gall stone
Case 234/M Presented with RUQ pain ,
Indigestion
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LFT :TB 3 mg/dl [0.3-1 mg/dl] DB 0.2 mg/dl [0.1-0.3 mg/dl]
AST 30 U/L [0-35 U/L] ALT 30 U/L [0-35 U/L]
ALP 100 U/L [30-120 U/L]
alb 4 g/dl [3.5-5.5 g/dl] glob 3 g/dl [1.5-3.5 g/dL]
Case 3 6y/m presented with increasing jau
ndice during illnesses with self remission
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General categories of LFTs
Transport organic anions & metabolize drugs Bilirubin, ICG
Hepatocyte injury
AST, ALT, LDH Cholestasis
ALP, GGT
Biosynthetic capacity Albumin, cholesterol, PT, clotting factor
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Liver Function Test
Liver chemistry test Clinical implication of abnormality
ALT Hepatocellular damage
AST Hepatocellular damage
Bilirubin Cholestasis, impair conjugation, or biliary obstruction
ALP Cholestasis, infiltrative disease, or biliary obstruction
PT Synthetic function
Albumin Synthetic function
GGT Cholestasis or biliary obstruction
Bile acids Cholestasis or biliary obstruction
5`-nucleotidase Cholestasis or biliary obstruction
LDH Hepatocellular damage, not specific
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Liver Function Test
Mild
(times)
Moderate
(times)
Marked
(times)
AST 20
ALT 20
ALP 5
GGT 10
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Bilirubin
Production/hepatic removal Overproduction
Uptake, conjugation, excretion
Regurgitation
Uncomplicated hemolysis < 3-5 mg/dL
Parenchymal liver dis, Calculi < malignant obstruction
Clay color stool: usually cholestatic, hepatocellular possible,not hemolytic
Dark urine: direct hyperbilirubinemia, usually cholestatic
30-50 mg/dL : renal failure
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Unconju. Conjugated
Van den Bergh reaction Indirect Direct
Water solubility - +
Lipid solubility + -
Albumin attachment + +
Icteric urine - +
Bile - +
Brain affinity + -
Hemolysis ++ +/-
Obstructive/hepatocellular + +++
Unconjugated & conjugated bilirubin
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Urinary bilirubin
Unconjugated bilirubin Tightly albumin bound
Not filtered not present in urine
100% of serum bilirubin by new precise methods
Unconjugated bilirubin
Both healthy & Gilbert syndrome
Urinary bilirubin +
Conjugated bilirubinemia Hepatobiliary disease
Low renal threshold
Normal serum bil level, no jaundice
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Aminotransferase (transaminase)
Liver cell injury AST (SGOT), ALT (SGPT)
Present in serum in low concentration: source?
AST: liver, cardiac m., skeletal m.,kidney, brain,
pancreas, lung, WBC, RBC No tissue specific isoenzyme
Damage or permeability
Clearing AST > ALT
By RES
Not biliary or urinary excretion
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AST ALTcatalyze transfer aminogroups to form pyruvate catalyze transfer aminogroups to form oxaloacetatecytosol (20%) and
mitochondria (80%) cytosol
T1/2 17 hr. (cytosol)
87 hr. (mitochondria) T1/2 47 hr.liver, cardiac muscle,
skeletal muscle, kidneys,brain, pancreas, lungs,leucocytes, and RBC
low concentration in other
tissues
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AST/ALT ratio
Location ALT: cytosol
AST: cytosol most circulating AST in healthy
mitochondria 80% of activity in the liver
ALT: more sensitive & specific
ALT < 300 IU, AST/ALT ratio >2 or >3: ALD
Noninvasive indicator of cirrhosis
Very specific (94-100%) but Not sensitive (44-75%)
AST/ALT < 1 : viral hepatitis, NASH
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Alkaline phosphatase
Function, degradation site? Canalicular membrane of hepatocyte, osteoblast,
brush border of intestine, Proximal convolutedtubules, placenta, WBC
Half life: 7 days
Higher in older & men (15-50 years old)
Normally elevated in adolescents & late pregnancy
Elevation: hepatobiliary disease, bone orpregnancy > intestine > kidneys
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0
10
20
30
40
50
60
70
80
90
alcoholic post necrotic
cirrhosis
chronic
hepatitis
obstructive
jaundice
viral hepatitis
AST/ALT >1
AST/ALT >2
AST/ALT ratio
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Aminotransferases levels
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Principal diagnostic value
75% of prolonged cholestasis pts > 4 WNL No difference between extra and intrahepaticobstruction
Isolated elevation
Partial bile duct obstruction: stone, tumor Infiltrative disease: sarcoidosis, abscesses, Tb,
metastatic carcinoma
Elevation in cancer patients
Bone or hepatic metastasis
Tumor secretion / leakage of hepaticphosphatase
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Principal diagnostic value II
Elevation < 4 WNL Nonspecific
Viral hepatitis, CH, LC, infiltrative disease
Moderate elevations Hodgkins disease, CHF, myeloid metaplasia,
intraabdominal infections, osteomyelitis
Familial
Extremely low level
Wilson disease with hemolysis
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-Glutamyl Transpeptidase
Cell membrane in kidney, pancreas, liver, spleen,heart, brain, seminal vesicle; not in bone
Normally exist in serum (0-30 IU/L)
No change during pregnancy
Clinically elevated in disease of liver, biliary tract,pancreas
Clinical value: DDx of elevated ALP, alcohol abuse
Not elevated in bone disease
Not elevated in childhood & pregnancy
GGT/ALP > 3: alcohol, drug
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-Glutamyl Transpeptidase
Isolated elevation of GGT Medication: barbiturate, phenytoin,
anticonvulsant, warfarin
Alcohol
Induction of hepatic microsomal GGT by EtOH ordrugs
Leakage from hepatocyte by alcohol
Fatty liver disease
Insulin resistance, visceral fat, fatty liver
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Albumin
300-500 g in body fluids Synthesize 15 g/d
Half life: 20 days
4% degraded daily
Regulation of synthesis: Nutrition, osmotic pressure,systemic inflammation, hormone
AA, corticosteroid, thyroid hormone
Alcohol, inflammation Chronic liver disease, heavy alcohol ingestion,
chronic infection, malnutrition, protein loosingenteropathy, nephrotic syndrome
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Prothrombin time
I, II, V, VII, IX, X, XII, XIII Half life < 24h
Congenital, consumption, warfarin, Vitamin Kdeficiency, parenchymal liver disease
Vitamin K 5- 10 mg parenteral injection
Improves 30% within 24 hours
Not sensitive but highly prognostic
Alcoholic steatonecrosis, hepatocellular disease,acetaminophen overdose
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Diagnostic approach in elevated serum bilirubin
elevated bilirubin
History and PE
unconjugated bilirubin
normal ALP, ALT, AST
conjugated bilirubin
normal ALP, ALT, AST abnormal ALP, ALT, AST
Rotors syndrome AST, ALT ALP
Dubin-Johnson syndrome predominate predominatehemolysis studies,review medications
as elevated
ALT evaluation U/S
ERCP as elevated ALT evaluation
review medications
AMA, ERCP, liver biopsy
present absent
//
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Thank You