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Liver Function Test

Piyanant Chonmaitree, MD. Department of Medicine Srinakharinwirot University

Liver Function Test


Liver chemistry test ALT AST Bilirubin ALP PT Albumin GGT Bile acids 5`-nucleotidase LDH Clinical implication of abnormality Hepatocellular damage Hepatocellular damage Cholestasis, impair conjugation, or biliary obstruction Cholestasis, infiltrative disease, or biliary obstruction Synthetic function Synthetic function Cholestasis or biliary obstruction Cholestasis or biliary obstruction Cholestasis or biliary obstruction Hepatocellular damage, not specific

Normal Laboratory Values


Normal Abnormal

2 SD normal values = mean 2SD of normal population

Liver Function Test


interpretation must be performed within the context of the patients risk factors, symptoms, concomitant conditions, medications, and physical findings rarely provide specific Dx, but rather suggest a general category of liver disease differing laboratories differing normal values

Liver Function Test


Mild (times) AST ALT ALP GGT <2-3 <2-3 <1.5-2 <2-3 Moderate (times) 2-3 to 20 2-3 to 20 1.5-2 to 5 2-3 to 10 Marked (times) >20 >20 >5 >10

Liver Function Test


should be evaluated and Rx in more expeditious manner
marked abnormalities S&S of chronic liver disease or decompensation

mild elevation is nonspecific and usually normal when repeated


observe vs. additional evaluation must be made in context of clinical scenario

Liver Function Test


Advantages sensitive, noninvasive method of screening liver dysfunction pattern of laboratory test abnormalities to recognize type of liver disorder assess severity of liver dysfunction follow cause of liver disease Disadvantages lack sensitivity
normal results in serious liver disease

not specific for liver dysfunction seldom lead to specific diagnosis

Initial Approach
history and physical examination algorithm approach useful mainly when no clinical clues
history patients symptoms risk factors for liver disease concomitant conditions medications occupational exposure to hepatotoxins physical examination body habitus splenomegaly ascites cutaneous stigmata of chronic liver disease

Liver Function Test


classified in 3 groups synthetic function : albumin, PT hepatocyte injury : AST, ALT cholestasis : bilirubin, ALP, GGT PT, albumin, bilirubin-most common tests used as prognostic factors

Albumin
depend on nutrition, volume status, vascular integrity, catabolism, hormone, loss in stool and urine not specific for liver disease T1/2 19-21 D
not reliable indicator of acute liver disease

Hypoalbuminemia
globulin 1.decrease synthesis -protein malnutrition -chronic liver disease -chronic inflammation 2.increase loss -PLE -NS 3.increase Vd (ascites, overhydration) 4.increase turnover (catabolic state, steroid) chol/TG Hb

Globulin
produced by stimulated B lymphocyte elevation in chronic liver disease chronic inflammation and malignant disease

40 2 PE : T 37 C, markedly pale, no jaundice, koilonychia, glossitis, coarse hair, no sign of chronic liver disease, liver and spleen not palpated LFT : TB 1 mg/dl [0.3-1 mg/dl] DB 0.2 mg/dl [0.1-0.3 mg/dl] AST 35 U/L [0-35 U/L] ALT 35 U/L [0-35 U/L] ALP 100 U/L [30-120 U/L] alb 1.8 g/dl [3.5-5.5 g/dl] glob 2 g/dl [1.5-3.5 g/dL] chol 80 mg/dl [<200] LFT

Case 1

40 2 PE : T 37 C, not pale, no jaundice, no sign of chronic liver disease, liver and spleen not palpated LFT : TB 1 mg/dl [0.3-1 mg/dl] DB 0.2 mg/dl [0.1-0.3 mg/dl] AST 35 U/L [0-35 U/L] ALT 35 U/L [0-35 U/L] ALP 100 U/L [30-120 U/L] alb 1.8 g/dl [3.5-5.5 g/dl] glob 2 g/dl [1.5-3.5 g/dL] chol 250 mg/dl [<200] LFT

Case 2

40 2 PE : T 37.8 C, mildly pale, no jaundice no sign of chronic liver disease, liver and spleen not palpated, shifting dullness + LFT : TB 1 mg/dl [0.3-1 mg/dl] DB 0.2 mg/dl [0.1-0.3 mg/dl] AST 35 U/L [0-35 U/L] ALT 35 U/L [0-35 U/L] ALP 100 U/L [30-120 U/L] alb 1.8 g/dl [3.5-5.5 g/dl] glob 4.5 g/dl [1.5-3.5 g/dL] chol 100 mg/dl [<200] LFT

Case 3

40 2 PE : T 37 C, mildly pale, no jaundice, spider nevi, palmar erythrema, liver and spleen not palpated, shifting dullness + LFT : TB 1 mg/dl [0.3-1 mg/dl] DB 0.2 mg/dl [0.1-0.3 mg/dl] AST 35 U/L [0-35 U/L] ALT 35 U/L [0-35 U/L] ALP 100 U/L [30-120 U/L] alb 1.8 g/dl [3.5-5.5 g/dl] glob 4.5 g/dl [1.5-3.5 g/dL] chol 100 mg/dl [<200] LFT

Case 4

Prothrombin time
liver synthesize coagulation factor except FVIII most present in excess, clotting abnormal occur only when substantial impairment in ability of liver to synthesis PT : FI, II, V, VII, IX and X T1/2 FVII 6 hrs. (shortest) prognosis : acute, chronic hepatocellular disease

Prothrombin time
prolonged : vitamin K deficiency (malnutrition, malabsorption, antibiotics) massive transfusion congenital disease liver disease warfarin DIC

Prothrombin time
in vit K deficiency, vit K 10 mg SC decrease prolong PT >30% within 24 hrs. INR : no advantage over PT

AST and ALT


most frequent used markers of hepatocellular necrosis, but not correlate with eventual outcome decrease : recovery or poor prognosis
poor prognosis : rapid fall with rising of bilirubin and PT

AST catalyze transfer amino groups to form pyruvate cytosol (20%) and mitochondria (80%) T1/2 17 hr. (cytosol) 87 hr. (mitochondria) liver, cardiac muscle, skeletal muscle, kidneys, brain, pancreas, lungs, leucocytes, and RBC

ALT catalyze transfer amino groups to form oxaloacetate cytosol T1/2 47 hr. low concentration in other tissues

AST, ALT
level of transminase elevation predominant AST elevation rate of transaminase declination

ALT and AST


>15 times : acute hepatic injury 5-15 times : less useful <5 times : chronic hepatic injury improved acute hepatic injury

AST/ALT ratio
< 1 : majority of liver disease >2
extrahepatic source alcoholic hepatitis ischemic and toxin acute Wilsons disease : hemolysis cirrhosis

>4 : fulminant Wilsons disease

AST/ALT ratio
90 80 70

60

50

40

AST/ALT >1 AST/ALT >2

30

20

10

alcoholic

post necrotic cirrhosis

chronic hepatitis

obstructive jaundice

viral hepatitis

Rate of Transaminase Declination


rapid ischemic short half life drug acute biliary tract obstruction fulminant hepatitis slow acute viral hepatitis long half life drug AIH metabolic disease

ALT and AST < 5 times


ALT predominant Chronic hepatitis B, C Acute hepatitis (A-E, EBV, CMV) Steatohepatitis Hemochromatosis Medications/toxins Autoimmune hepatitis Alpha1-antitrypsin deficiency Wilsons disease Celiac disease
*almost any types of liver disease

AST predominant Alcohol-related liver injury Steatohepatitis Cirrhosis Drug Nonhepatic


Hemolysis Myopathy Thyroid disease Strenuous exercise

Macro AST

Risk factor of chronic viral hepatitis


injection drug use birth to mother with HBV blood transfusion prior to 1992 needle stick from a donor subsequently testing positive for HBV or HCV chronic hemodialysis unvaccinated health care workers homosexual body piercing or tattooing

Common medication
Acetaminophen overdose Statins NSAIDs Antibiotics Antiepileptics Antituberculosis drugs Herbal remedies, alternative medications and substance abuse

ALT and AST < 5 times


discontinue all nonessential medications if mild elevation and essential medications must be continued
if liver enzyme elevations continue to rise, suspect medication should be stopped long-term effects of chronic, medication induced hepatotoxicity are lacking for many drugs

Case 5
40 LFT : TB 1 mg/dl [0.3-1 mg/dl] DB 0.2 mg/dl [0.1-0.3 mg/dl] AST 75 U/L [0-35 U/L] ALT 90 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] LFT management

Case 5.1
40 , BW 90 kg, Height 160 cm., truncal obesity LFT :TB 1 mg/dl [0.3-1 mg/dl] DB 0.2 mg/dl [0.1-0.3 mg/dl] AST 75 U/L [0-35 U/L] ALT 90 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] management

Diagnostic approach in mild elevations of the serum AST and ALT elevated ALT and AST < 5X history and PE, discontinue hepatotoxic medications confirm abnormality if an error is suspected liver chemistries, PT, albumin, CBC, hepatitis A, B and C serologies, Fe, TIBC, Ferritin
negative positive

negative, asymptomatic, no decompensation

lifestyle modification
discontinue alcohol and hepatotoxic drug, weight loss, diabetes control

consider U/S, ANA, ASMA, ceruloplasmin, alpha-1 antitrypsin liver biopsy

consider as specific disease

repeat liver chemistries


normal

abnormal

observe

U/S, ANA, ASMA, ceruloplasmin, alpha-1 antitrypsin liver biopsy

Case 5.1
40 , BW 90 kg, Height 160 cm., truncal obesity LFT :TB 1 mg/dl [0.3-1 mg/dl] DB 0.2 mg/dl [0.1-0.3 mg/dl] AST 75 U/L [0-35 U/L] ALT 90 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] viral profile-negative

NAFLD/NASH
NAFLD = macrovesicular steatosis with mild or without inflammation, no fibrosis NASH = NAFLD + inflammation/ ballooning/fibrosis alcohol <70 g/D in women, <140 g/D in men 2 hits hypothesis
hyperinsulinemia increased FFA in liver steatosis hepatocyte necrosis and inflammation

NAFLD/NASH
asymptomatic, vague RUQ pain, fatigue, malaise hepatomegaly, splenomegaly, spider angiomata, palmar erythema, ascites AST, ALT 2-4x, AST/ALT<1 1/3 ALP slightly elevated

NAFLD/NASH
U/S bright liver CT-lower density than spleen MRI-bright on T1W biopsy (gold standard) : macrovesicular steatosis, parenchymal inflammation, hepatocyte necrosis, ballooning hepatocyte degeneration

NAFLD/NASH
weight reduction, exercise, control DM and dyslipidemia orlistat, sibutramine, Bariatric surgery avoidance of toxins : drugs, alcohol insulin sensitizing agents
thiazolidinediones metformin

Case 5.2
40 IVDU LFT :TB 1 mg/dl [0.3-1 mg/dl] DB 0.2 mg/dl [0.1-0.3 mg/dl] AST 75 U/L [0-35 U/L] ALT 90 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] investigation

Case 5.2
40 IVDU LFT :TB 1 mg/dl [0.3-1 mg/dl] DB 0.2 mg/dl [0.1-0.3 mg/dl] AST 75 U/L [0-35 U/L] ALT 90 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] HBsAg positive antiHCV negative

ALT and AST < 5 times and AST predominant


history alcohol intake (history from patient and family members) hemolysis studies aldolase CPK macro-AST

Case 6
40 LFT :TB 1 mg/dl [0.3-1 mg/dl] DB 0.2 mg/dl [0.1-0.3 mg/dl] AST 280 U/L [0-35 U/L] ALT 250 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] LFT management

Alcoholic hepatitis
appropriate history of alcoholic consumption, serologic exclusion of other liver disease 40-80 g/D, 20-40 g/D 10-12 yrs. characteristic pattern
AST rarely exceeds 300 IU/dl AST/ALT >1 in 92%, >2 in 70%
pyridoxine deficiency alcohol induces release of mitochondrial AST

GGT/ALP >2.5

Case 6
40 20

LFT :TB 1 mg/dl [0.3-1 mg/dl] DB 0.2 mg/dl [0.1-0.3 mg/dl] AST 280 U/L [0-35 U/L] ALT 250 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] LFT management

Alcoholic hepatitis
Rx abstinence alcohol drinking severe alcoholic hepatitis (DF >32)
[DF = 4.6 x (PT-control) + serum bilirubin] glucocorticoid (no GI bleeding and active infection) improve survival, not reduce HRS pentoxyfilline reduce HRS

ALT and AST > 15 times


Acute viral hepatitis (A-E, herpes) Medications/toxins Ischemic hepatitis Acute bile duct obstruction Autoimmune hepatitis Wilsons disease Acute Budd-Chiari syndrome Hepatic artery ligation Heat stroke

AST predominate : medication/toxin, ischemic  >75 times : ischemic, toxic, viral (less common)

Case 7
40 underlying disease AF, HT CHF LFT :TB 2 mg/dl [0.3-1 mg/dl] DB 1 mg/dl [0.1-0.3 mg/dl] AST 2500 U/L [0-35 U/L] ALT 2200 U/L [0-35 U/L] ALP 180 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] LFT, DDx management

(shock liver, acute hepatic circulatory insufficiency)

Ischemic hepatitis

low-flow hemodynamic state


hypotension, sepsis, cardiac arrhythmia, MI, HF, hemorrhage, extensive burns, severe trauma, heat stroke

hypotension often not documented usually subclinical

Ischemic hepatitis
sudden and massive (>2000) elevation of liver enzyme, tend to decrease rapidly and return normal within 1 wk. mild and transient elevation of bilirubin (80% < 2 mg/dl) and ALP extreme elevation LDH (>5000), ALT/LDH < 1.5 rare acute liver failure Rx and prognosis underlying disease

Ischemic hepatitis

Case 8
40 RUQ pain 12 LFT :TB 2 mg/dl [0.3-1 mg/dl] DB 1.5 mg/dl [0.1-0.3 mg/dl] AST 1200 U/L [0-35 U/L] ALT 1400 U/L [0-35 U/L] ALP 180 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] LFT, DDx management

Acute biliary obstruction


aminotransferase peak early and decline rapidly over 24-72 hr. despite unresolved obstruction after aminotransferase decrease, bilirubin and ALP increase 25% of patients with AST > 10X

Acute biliary obstruction

Case 8
40 RUQ pain 12 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] alb 4 g/dl [3.5-5.5 g/dl] glob 3 g/dl [1.5-3.5 g/dL] U/S : bile duct dilatation with gall stone F/U LFT 72 hr. AST 300 U/L, ALT 600 U/L

LDH
non specific rhabdomyolysis, MI, hemolysis, stroke, renal infarction, acute or chronic liver disease use in
ischemic hepatitis : transient, massive elevation malignant infiltration of liver : sustained elevation with ALP

Bilirubin
UDP-glucoronyltransferase

RE cell HEME UCB

plasma UCB + albumin

hepatocyte UCB+ligandin BMG BDG bile

urobilinogen

stercobilinogen

Bilirubin
Direct bilirubin : reacted directly with reagent Indirect bilirubin : require addition of alcohol for color development Unconjugated bilirubin = indirect form Conjugated bilirubin = bilirubin mono and di-glucoronides

Diagnostic approach in elevated serum bilirubin elevated bilirubin History and PE unconjugated bilirubin normal ALP, ALT, AST conjugated bilirubin

hemolysis studies, review medications

Isolated unconjugated hyperbilirubinemia


IDB fraction > 85% of total bilirubin 1. increase production :
hemolysis
chronic hemolysis-not sustained increase of bilirubin >5 mg/dl in normal hepatic function

ineffective erythropoiesis : folate, IDA drug : rifampicin, ribavirin, probenecid resolution of hematoma Gilberts syndrome Crigler-Najjar syndrome

2. defects in hepatic uptake/conjugation

Case 9
30 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] LFT, DDx management

Gilberts syndrome
benign, unconjugated hyperbilirubinemia with otherwise normal liver chemistries up to 5% of normal population polymorphism in TATA box of gene encoding bilirubin UDP-GT impair ability to conjugate bilirubin prominent in fasting state, systemic illnesses, hemolysis, some medications

Gilberts syndrome
Dx :
asymptomatic, healthy mild unconjugated hyperbilirubinemia (<4 mg/dl) with otherwise normal liver chemistries test exclusion medications and hemolysis

Case 10
30 3 PE : T 38 C, markedly pale, mild jaundice, no sign of chronic liver disease, liver and spleen not palpated LFT : TB 5.4 mg/dl [0.3-1 mg/dl] DB 0.8 mg/dl [0.1-0.3 mg/dl] AST 120 U/L [0-35 U/L] ALT 45 U/L [0-35 U/L] ALP 110 U/L [30-120 U/L] alb 3.6 g/dl [3.5-5.5 g/dl] glob 3.6 g/dl [1.5-3.5 g/dL] LFT DDx management

Indirect Hyperbilirubinemia
Bilirubin hemolysis Gilberts syndrome 5 mg/dl 5 mg/dl AST, ALT increase AST normal Alb N N Glob N N PT N N

Diagnostic approach in elevated serum bilirubin elevated bilirubin History and PE unconjugated bilirubin normal ALP, ALT, AST conjugated bilirubin

Conjugated hyperbilirubinemia
DB > 50% of total bilirubin cant differentiate obstruction and parenchymal disease Delta fraction
CB tightly bound to albumin tendency of hyperbilirubinemia to resolve more slowly than other biochemical tests

Conjugated hyperbilirubinemia
Bile duct obstruction Hepatitis Cirrhosis Medications/Toxins Primary biliary cirrhosis Primary sclerosing cholangitis Sepsis Total parenteral nutrition Intrahepatic cholestasis of pregnancy Benign recurrent cholestasis Vanishing bile duct syndromes Dubin-Johnson syndrome Rotor syndrome

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 Dubin-Johnson syndrome

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 AST, ALT ALP Dubin-Johnson syndrome predominate predominate / /
Rotors syndrome as elevated ALT evaluation U/S

hemolysis studies, review medications

present

absent

ERCP

as elevated ALT evaluation review medications AMA, ERCP, liver biopsy

Case 11
30 3 PE : T 37 C, not pale, mild jaundice, no sign of chronic liver disease, liver and spleen not palpated LFT : TB 6.2 mg/dl [0.3-1 mg/dl] DB 4.8 mg/dl [0.1-0.3 mg/dl] AST 100 U/L [0-35 U/L] ALT 120 U/L [0-35 U/L] ALP 520 U/L [30-120 U/L] alb 3.6 g/dl [3.5-5.5 g/dl] glob 3.6 g/dl [1.5-3.5 g/dL] LFT management

Alkaline phosphatase
family of isoenzyme catalyze hydrolysis of No. of P esters at alkaline pH require Zn for activity present in nearly all tissues (liver, bone, intestinal, placenta, kidney) liver ALP
isoenzyme, 5-nucleotidase, GGT

Alkaline phosphatase
Physiologic >60 yr. child and adolescent pregnancy blood group O post meal (fatty meal) Pathologic intrahepatic extrahepatic

Alkaline phosphatase
Intrahepatic
viral alcohol drug pregnancy PBC PSC TPN sepsis vanishing bile duct syndrome benign recurrent cholestasis benign post-op. cholestasis paraneoplastic syndrome venoocclusive disease GVHD

Extrahepatic
intraluminal obstruction : gall stones, ascariasis, hemobilia disease of BD : PSC, choledochal cyst, cholangioCA, AIDS cholangiopathy external compression : LN, GB CA, Mirizzis syndrome, CA pancreas, ampullar adenoma

Alkaline phosphatase
in biliary obstruction
induction of ALP synthesis 2 to enhanced translation of mRNA ALP levels, may not rise until 1-2 days T1/2 1 wk, take several days for levels to normalise after resolution

in malignancy Regan isoenzyme


no identifiable liver/bone involvement biochemical distinct from liver ALP associated variety of different CA ex lung CA

Alkaline phosphatase
initial evaluation : determine hepatic or nonhepatic origin, concomitant elevation of other serum LFT level not a reliable indicator of severity of underlying liver disease degree not help to distinguish intrahepatic and extrahepatic

Isolated hepatic ALP elevation


Partial bile duct obstruction Medications Infiltrative liver disease Hepatic metastasis PBC PSC Hepatitis Cirrhosis Vanishing bile duct syndromes Benign recurrent cholestasis

Infiltrative diseases
modest (up to 3x) rise in aminotransferase, and up to 20x rise in ALP, bilirubin N-5x

TB Fungal infection HCC Lymphoma Metastatic malignancy Amyloidosis Sarcoidosis Other granulomatous diseases

Alkaline phosphatase
ALP > 1000 : malignant biliary obstruction, sepsis, AIDS with systemic infection decrease : hypothyroidism, pernicious anemia, Zn deficiency, congenital, Wilsons disease, severe hepatic insufficiency

Medications elevation of bilirubin and ALP


Anabolic steroid Allopurinol Amoxicillin-clavuronic acid Captopril Carbamazepine Chlorpropamide Cyproheptadine Diltiazem Erythromycin Estrogens Floxuridine Flucloxacillin Fluphenazine Gold salts Imipramine Indinavir Iprindole Nevirapine Methytestosterone Methylenedioxymethamphetam ine Oxaprozin Pizotyline Quinidine Tolbutamide TPN Trimethoprimsulfamethoxazole

Diagnostic approach in elevated serum alkaline phosphatase elevated ALP History and PE normal bilirubin, ALT, AST GGT or 5nucleotidase
negative positive

abnormal liver chemistries U/S

yes

no

not hepatobiliary

no duct dilatation

U/S review medication AMA liver biopsy

ERCP

AMA

negative

observation
> 6 months

as elevated ALT evaluation, liver biopsy, ERCP

40 LFT : TB 1 mg/dl [0.3-1 mg/dl] DB 0.2 mg/dl [0.1-0.3 mg/dl] AST 35 U/L [0-35 U/L] ALT 35 U/L [0-35 U/L] ALP 320 U/L [30-120 U/L] alb 1.8 g/dl [3.5-5.5 g/dl] glob 2 g/dl [1.5-3.5 g/dL] LFT

Case 12

-glutamyltransferase (GGT)
catalyzed transfer of -glutamyl groups of peptides to other amino acid abundant in liver, kidney, pancreas, intestine, and prostate, spleen, heart, brain but not in bone T1/2
7-10 days 28 days in alcohol-associated liver injury

-glutamyltransferase (GGT)
increase
alcohol drug anticonvulsant (CBZ, phenytoin, and barbiturate), warfarin, OC almost all type of liver diseases COPD, renal failure, DM, hyperthyroidism, RA, AMI, pancreatic disease

40 LFT : TB 1 mg/dl [0.3-1 mg/dl] DB 0.2 mg/dl [0.1-0.3 mg/dl] AST 35 U/L [0-35 U/L] ALT 35 U/L [0-35 U/L] ALP 320 U/L [30-120 U/L] alb 1.8 g/dl [3.5-5.5 g/dl] glob 2 g/dl [1.5-3.5 g/dL] GGT 86 [0-50] LFT

Case 12

Summary
Hepatocellular necrosis toxin/ ischemia AST/ALT ALP Bilirubin PT albumin 50-100X 1-3X 1-5X viral 5-50X 1-3X 1-30X alcohol 2-5X 1-10X 1-30X Biliary obstruction complete 1-5X 2-20X 1-30X partial 1-5X 2-10X 1-5X 1-3X 1-20X 1-5X normal normal Infiltration

increase in severe, unresponsive to vit K increase in subacute/chronic

increase, responsive to vit K usually normal, decrease in advance

Take home message


initial evaluation : assess in clinical context classified in 3 groups  synthetic function : albumin, clotting time  cholestasis : bilirubin, ALP, GGT  hepatocyte injury : AST, ALT

Liver Function Test


misnomer
not effectively assess actual function not always specific for the liver limited information regarding presence or severity of complication

Liver Chemistry Test

Liver Function Test


normal may have abnormal test normal value not ensure that patient is free of liver disease level of abnormality does not reflect severity but may help in DDx decrease in the value does not mean improvement limitation in sensitivity and specificity

Thank You