Академический Документы
Профессиональный Документы
Культура Документы
Weight Loss
9/13/2006
Nick Siebers, M.D.
HPI
Feeling well.
No abdominal pain, nausea, emesis,
jaundice or pruritits, fever, chills or night
sweats.
Does acknowledge a 20-30 pound
unintentional weight loss over last 18
months, although this has been stable
over last 4 months.
PMHx Contd
ROS
Exam
Is it a real problem?
Gilbert's syndrome
Dubin-Johnson syndrome
Rotor syndrome
Viral hepatitis:
Hepatitis A
Hepatitis B
Hepatitis C
Hepatitis D
Hepatitis E
Cholestatic syndromes
Jaundice of sepsis
Cholestasis of pregnancy
Biliary atresia
Caroli's disease
Cryptosporidiosis
Vascular injury
Venoocclusive disease
Budd-Chiari syndrome
Ischemic hepatitis
Passive congestion
Mass lesions
Hepatocellular carcinoma
Cholangiocarcinoma
Adenoma
Metastatic tumors
Abscess
Cysts
From Harrison's Internal Medicine Copyright 2006 The McGraw-Hill
Companies. All rights reserved.
NHANES 1999-2002
When history of excessive alcohol
consumption and Hep C antibody
positive excluded :
ALT abnormal 7.3%
AST abnormal 3.6%
Either 8.1%
Increased compared with NHANES 19881994 but possibly from differences in
specimen handling
NHANES 1988-1994
7.9% with elevated ALT or AST
31% of these were explained by alcohol
consumption, Hep B or C or high
transferrin saturation.
69% were not!
Up To Date Recommendations
Approach to the patient with abnormal
liver function tests - Daniel S. Pratt author
4 step approach to chronically abnormal
aminotransferases
1) Check for common liver diseases
2) Check for non-hepatic causes
3) Check less common liver diseases
4) Biopsy or observe
2) Non-Hepatic sources
Muscle disorders
Thyroid disease, hypo- or hyperthyroidism
Celiac disease
Adrenal Insufficiency
Autoimmune hepatitis
Wilsons disease (if less than 40 y/o)
Alpha-1-antitrypsin deficiency
Other diagnoses
AST 28 (0-50)
ALT 66 (0-65)
Alk Phos 134 (35-130)
Total bili 0.6
GGT 23
Iron 138
TIBC 313
Iron Saturation 44%
Hepatitis A and B serologies (-)
CEA < 0.7 undetectable
Thyroid tests?
% with abnormality
AST
27%
ALT
37%
Alk Phos
64%
GGT
17%
Bilirubin
5%
ANY
76%
Mr. N
Seen by endocrine! And his thyroid wasnt felt to
be enlarged.
Being treated for Graves Disease with PTU,
plan treatment for one year then withdraw and
monitor.
ALT has normalized, alk phos up slightly
He feels great and is VERY happy with these
results decreased tremor and anxiety, better
sleep, weight going up, no cancer.
Per Dr. Nolten hyperthyroidism is likely the
cause of his abnormal liver tests.
Conclusions
Work up common liver diseases first, with
focus as per history
If abnormal liver tests think of the
thyroid!
It is possible to get a patient in to see
endocrine, although it takes some doing.
References
Pratt, DS. Approach to the patient with abnormal liver function tests. Up To Date
2006.
Katkov, WN, et al. Elevated serum alanine aminotransferase levels in blood donors:
the contiburion of hepatitis C virus. Annals ot Internal Medicine 1991; 115:882.
Hulcrantz, R, et al. Liver investigations in 149 asymptomatic patients with moderately
elevated activities of serum aminotransferases. Scandanavian Journal of
Gastroenterology 1986; 21:109.
Ioannou, GN, et al. the Prevalence and Predictors of Elevated Serum
Aminotransferase Activity in the United States in 1999-2002. American Journal of
Gastroenterology 2006; 101:76-82.
Huang, M, et al. Sequential Liver and Bone Biochemical Changes in Hyperthyroidism:
Prospective Controlled Follow-up Study. American Journal of Gastroenterology 1994;
89:1071-1076
Fong, T, Et al. Hyperthyroidism and Hepatic Dysfunction: A case Series Analysis.
Journal of Clinical Gastroenterology 1992; 14:240-244.
Leeuwenburgh, I, et al. Recovery of Chronic Hepatitis by Treatment of Concomitant
Hyperthyroidism. European Journal of Gastroenterology and Hepatology 2001:
13:1389-1392.
Harrison's Internal Medicine Online - Copyright 2006