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normal
normal
range
range
Liver
Liver
Function
Function
Tests
Tests
ALT: alanine aminotransferase (SGPT)
ALT: alanine aminotransferase (SGPT)
AST: aspartate aminotransferase (SGOT)
AST: aspartate aminotransferase (SGOT)
Alkaline Phosphatase & Bilirubin
Alkaline Phosphatase & Bilirubin
Known as LFT
Known as LFT
s (but they
s (but they
re really not)
re really not)
Liver Synthetic Function
Liver Synthetic Function
Total Protein and serum albumin
Total Protein and serum albumin
Total
Total
Bilirubin
Bilirubin
Prothrombin Time (PT / INR)
Prothrombin Time (PT / INR)
These are
These are
true
true
s
s
ALT:
ALT:
Found primarily in hepatocytes
Found primarily in hepatocytes
Released when cells are hurt or destroyed
Released when cells are hurt or destroyed
Normal levels depend on the reference
Normal levels depend on the reference
range which actually differs lab to lab
range which actually differs lab to lab
Considered normal between 5
Considered normal between 5
-
-
40 U/L
40 U/L
Probably should be half of this (5
Probably should be half of this (5
-
-
20?)
20?)
Traditional LFT
Traditional LFT
s
s
AST:
AST:
Found in many sources, including liver,
Found in many sources, including liver,
heart, muscle, intestine, pancreas
heart, muscle, intestine, pancreas
Not very specific for liver disease
Not very specific for liver disease
Often follows ALT to a degree
Often follows ALT to a degree
Elevated 2 or 3:1 (vs. ALT) in alcoholics
Elevated 2 or 3:1 (vs. ALT) in alcoholics
Normal range: 8
Normal range: 8
-
-
20 U/L
20 U/L
Traditional LFT
Traditional LFT
s
s
Alkaline Phosphatase:
Alkaline Phosphatase:
Found in liver (especially biliary tract),
Found in liver (especially biliary tract),
bones, intestines, & placenta
bones, intestines, & placenta
Fractionated
Fractionated
or
or
isoenzymes
isoenzymes
to source
to source
Liver AP rises with obstruction or
Liver AP rises with obstruction or
infiltrative diseases (i.e., stones or tumors)
infiltrative diseases (i.e., stones or tumors)
Normal range: 20
Normal range: 20
-
-
70 U/L
70 U/L
Traditional LFT
Traditional LFT
s
s
Bilirubin: two primary sources
Bilirubin: two primary sources
Indirect (unconjugated): old red cells,
Indirect (unconjugated): old red cells,
removed by the spleen, sent to the liver
removed by the spleen, sent to the liver
Liver
Liver
adds
adds
s
s
Bilirubin: Indirect and direct
Bilirubin: Indirect and direct
Direct (conjugated): Total bilirubin includes
Direct (conjugated): Total bilirubin includes
both direct and indirect types
both direct and indirect types
Excreted in the bile, down the common
Excreted in the bile, down the common
bile duct, into the small intestine
bile duct, into the small intestine
Normal range: 0.3
Normal range: 0.3
1.0 mg/ dL
1.0 mg/ dL
Patterns of Abnormal
Patterns of Abnormal
Elevations in ALT & AST only: suggests
Elevations in ALT & AST only: suggests
cellular injury
cellular injury
Elevations in Alk Phos & Bilirubin:
Elevations in Alk Phos & Bilirubin:
suggests cholestasis or obstruction
suggests cholestasis or obstruction
Mixed pattern: ALT, AST, AP & Bili:
Mixed pattern: ALT, AST, AP & Bili:
probably the most common scenario
probably the most common scenario
Patterns of Abnormal
Patterns of Abnormal
Consider degree of elevation:
Consider degree of elevation:
Very high ALT and AST usually only come
Very high ALT and AST usually only come
from a couple of sources:
from a couple of sources:
Acute viral hepatitis (A,B,C, HSV)
Acute viral hepatitis (A,B,C, HSV)
Acetominophen
Acetominophen
toxicity / overdose
toxicity / overdose
Shock Liver
Shock Liver
Gold Standard
Gold Standard
for diagnosis
for diagnosis
Biopsy is second only to a good history
Biopsy is second only to a good history
If a biopsy is obtained, you
If a biopsy is obtained, you
ll need a very
ll need a very
experienced pathologist to read it
experienced pathologist to read it
Consider sending it out if your local
Consider sending it out if your local
expertise is suspect
expertise is suspect
Evaluation Strategy
Evaluation Strategy
Advanced Imaging:
Advanced Imaging:
If RUQ US is questionable, and you
If RUQ US is questionable, and you
re
re
looking at a mixed picture:
looking at a mixed picture:
Consider an MRCP: non
Consider an MRCP: non
-
-
invasive,
invasive,
sensitive for
sensitive for
ductal
ductal
dilation (CBD,
dilation (CBD,
pancreatic ducts). Diagnostic, but non
pancreatic ducts). Diagnostic, but non
-
-
therapeutic.
therapeutic.
ERCP: Therapeutic, risk of pancreatitis,
ERCP: Therapeutic, risk of pancreatitis,
not available everywhere
not available everywhere
Spider
Spider
Angiomata
Angiomata
Spider Nevi
Spider Nevi
Nail Clubbing
Nail Clubbing
Dupuytren's Contracture
Ascites
Ascites
J aundice or
J aundice or
Scleral
Scleral
Icterus
Icterus
Evaluation Strategy
Evaluation Strategy
Clinical Pearls:
Clinical Pearls:
Acute hepatitis panels
Acute hepatitis panels
never
never
consider acute
consider acute
HCV. If you have a IVDA pt, consider an HCV
HCV. If you have a IVDA pt, consider an HCV
PCR for acute hepatitis C. HIV?
PCR for acute hepatitis C. HIV?
Consider celiac
Consider celiac
sprue
sprue
for abnormal LFT
for abnormal LFT
s,
s,
especially if you get a vague history of
especially if you get a vague history of
dyspepsia. Order TTG (tissue
dyspepsia. Order TTG (tissue
transglutaminase
transglutaminase
antibodies) with AGA (anti
antibodies) with AGA (anti
gliadin
gliadin
antibodies).
antibodies).
Summary
Summary
Liver tests are numerous and somewhat
Liver tests are numerous and somewhat
confusing
confusing
Not all liver disease is associated with
Not all liver disease is associated with
abnormal test results
abnormal test results
Some of the worst liver disease has
Some of the worst liver disease has
relatively normal appearing LFT
relatively normal appearing LFT
s and can
s and can
only be noticed with a look at synthetic
only be noticed with a look at synthetic
functions
functions
Summary
Summary
All
All
abnormal liver tests should be
abnormal liver tests should be
investigated
investigated
Referral to an expert is absolutely needed
Referral to an expert is absolutely needed
Liver biopsy is the
Liver biopsy is the
Gold Standard
Gold Standard
for
for
diagnosis
diagnosis
Family histories of liver disease should be
Family histories of liver disease should be
noted:
noted:
.
.
my grandmother died of
my grandmother died of
cirrhosis, but she never drank
cirrhosis, but she never drank
.
.
Thank You!
Thank You!
My contact information:
My contact information:
Ed Marino, PA
Ed Marino, PA
-
-
C
C
Porter Hospital Liver Transplant Service
Porter Hospital Liver Transplant Service
2535 S. Downing St., Suite #380
2535 S. Downing St., Suite #380
Denver, CO 80210
Denver, CO 80210
edwardmarino@centura.org
edwardmarino@centura.org
Wk. 303.778.5797 Fax 303.778.5205
Wk. 303.778.5797 Fax 303.778.5205