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Abnormal LFT’s: Patient Evaluation Esther A. Torres MD, Esther A. Torres MD, MACP, MACG, AGAF UPR Sh l fM di i UPR School of Medicine
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Abnormal LFT’s: Patient Evaluation...Abnormal LFT’s: Patient Evaluation Take-home points • Abnormalities of ALT and AST are common – Medications are the first thing to look

Dec 26, 2019

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Page 1: Abnormal LFT’s: Patient Evaluation...Abnormal LFT’s: Patient Evaluation Take-home points • Abnormalities of ALT and AST are common – Medications are the first thing to look

Abnormal LFT’s: Patient Evaluation

Esther A. Torres MD,Esther A. Torres MD, MACP, MACG, AGAF

UPR S h l f M di iUPR School of Medicine

Page 2: Abnormal LFT’s: Patient Evaluation...Abnormal LFT’s: Patient Evaluation Take-home points • Abnormalities of ALT and AST are common – Medications are the first thing to look

Abnormal LFT’s: GoalsAt the end of the session,

you should:you should:• Recognize when abnormal liver tests are

significant• Determine the most probable cause (s) for p ( )

the abnormality in your patient• Choose the appropriate diagnostic strategyChoose the appropriate diagnostic strategy• Refer to a specialist in a timely fashion

Page 3: Abnormal LFT’s: Patient Evaluation...Abnormal LFT’s: Patient Evaluation Take-home points • Abnormalities of ALT and AST are common – Medications are the first thing to look

Abnormal LFT’s: definitionsAbnormal LFT s: definitions• What are “liver function tests”?What are liver function tests ?

– “Hepatic (liver) panel/profile”– Albumin, PT: synthetic functionAlbumin, PT: synthetic function– Bilirubin: detoxification of metabolites and

transportation of organic ions– Indicate severity (ex. Child’s score)

• Which tests are the indicators of injury ordamage?– Aminotransferases (ALT, AST)– Alk Phos– GGT

Page 4: Abnormal LFT’s: Patient Evaluation...Abnormal LFT’s: Patient Evaluation Take-home points • Abnormalities of ALT and AST are common – Medications are the first thing to look

Abnormal LFT’s: definitions• ALT and AST

– Markers of hepatocellular necrosis– Damage or destruction of tissue rich in AST

and ALT or changes in cell membrane bilit ll i l k i tpermeability allowing leakage into serum

– AST (cytosol and mitochondria): liver, cardiac and skeletal muscle kidneys brain pancreasand skeletal muscle, kidneys, brain, pancreas, lungs, WBC’s, RBC’s

– ALT (cytosol): mostly liver

Page 5: Abnormal LFT’s: Patient Evaluation...Abnormal LFT’s: Patient Evaluation Take-home points • Abnormalities of ALT and AST are common – Medications are the first thing to look

Abnormal LFT’s: definitions

AST and ALT:D th l l f l ti• Do the levels of elevation mean anything?–how normal is “normal”?

“know your ALT”– know your ALT• AST/ALT

Page 6: Abnormal LFT’s: Patient Evaluation...Abnormal LFT’s: Patient Evaluation Take-home points • Abnormalities of ALT and AST are common – Medications are the first thing to look

Abnormal LFT’s: definitions

• Alkaline phosphatase– Liver, bone, intestine, kidney, placenta andLiver, bone, intestine, kidney, placenta and

WBC’s– 5’nucleotidase or GGT to establish liver origing

• Elevated Alk Phos mechanism: induction of enzyme synthesis and releaseenzyme synthesis and release (regurgitation) into the circulation

Page 7: Abnormal LFT’s: Patient Evaluation...Abnormal LFT’s: Patient Evaluation Take-home points • Abnormalities of ALT and AST are common – Medications are the first thing to look

Abnormal LFT’s: definitions

• Alk Phos ↑ : What does it mean?– CholestasisCholestasis– Infiltrative disease

• Significant levels: > 1 5 X ULN• Significant levels: > 1.5 X ULN– Pregnant and older women have higher values

GGT ll b f kid• GGT – cell membrane of kidney, pancreas, liver, spleen, heart, brain and seminal

i lvesicles

Page 8: Abnormal LFT’s: Patient Evaluation...Abnormal LFT’s: Patient Evaluation Take-home points • Abnormalities of ALT and AST are common – Medications are the first thing to look

Abnormal LFT’s: What to do?

• Document chronicity and liver origin• Is it significant?Is it significant?• History and physical exam

N h ?• Now what?

Page 9: Abnormal LFT’s: Patient Evaluation...Abnormal LFT’s: Patient Evaluation Take-home points • Abnormalities of ALT and AST are common – Medications are the first thing to look

Case # 1:Elevated ALT and AST

Page 10: Abnormal LFT’s: Patient Evaluation...Abnormal LFT’s: Patient Evaluation Take-home points • Abnormalities of ALT and AST are common – Medications are the first thing to look

Case # 1

A 46 y/o female is found with elevated ALT and AST d ring testing for ins rance p rposesand AST during testing for insurance purposes. Her history reveals transfusions for an ectopicpregnanc 30 ears ago “social” alcohol sepregnancy 30 years ago, “social” alcohol use, no history of hepatitis and no use of illicitdrugs She has no symptoms except mild jointdrugs. She has no symptoms except mild jointaches.

On physical exam she is overweight, with a BP of 150/90. No other significant findings are g gnoted.

Page 11: Abnormal LFT’s: Patient Evaluation...Abnormal LFT’s: Patient Evaluation Take-home points • Abnormalities of ALT and AST are common – Medications are the first thing to look

Case # 1

CBC, CMP, cholesterol and triglycerides show the following abnormalities:show the following abnormalities:

Cholesterol – 280 mg%

ALT - 89

AST - 78

Page 12: Abnormal LFT’s: Patient Evaluation...Abnormal LFT’s: Patient Evaluation Take-home points • Abnormalities of ALT and AST are common – Medications are the first thing to look

What are your possibleWhat are your possiblediagnosis?diagnosis?

How to confirm it?How to confirm it?

Page 13: Abnormal LFT’s: Patient Evaluation...Abnormal LFT’s: Patient Evaluation Take-home points • Abnormalities of ALT and AST are common – Medications are the first thing to look

Case # 1Case # 1

Chronic viral hepatitis HCVabDx Test

Chronic viral hepatitis HCVabHBsAg, HBsAb, HBcAb

NAFLDNAFLD

Autoimmune hepatitis s PEP

Any other ideas?

Page 14: Abnormal LFT’s: Patient Evaluation...Abnormal LFT’s: Patient Evaluation Take-home points • Abnormalities of ALT and AST are common – Medications are the first thing to look

Case # 1

• Hepatitis serology is negative• sPEP is normalsPEP is normal• Would you:

D lt d?– Do an ultrasound?– Do a liver biopsy?– Or?

• Would you give her statins?

Page 15: Abnormal LFT’s: Patient Evaluation...Abnormal LFT’s: Patient Evaluation Take-home points • Abnormalities of ALT and AST are common – Medications are the first thing to look

Some facts about NAFLDSome facts about NAFLD• Most common liver diseaseMost common liver disease

– 24% of population (NHANES III)R i f t t i th h• Ranging from steatosis throughsteatohepatitis (NASH) to cirrhosis

• Associated factors: obesity, dyslipidemia, metabolic syndrome, diabetes

• No proven therapy• Important predictor of CAD and diabetesp p

– do not ignore the ALT!!!

Page 16: Abnormal LFT’s: Patient Evaluation...Abnormal LFT’s: Patient Evaluation Take-home points • Abnormalities of ALT and AST are common – Medications are the first thing to look

Normal liverNormal liver

Fatty liver

Page 17: Abnormal LFT’s: Patient Evaluation...Abnormal LFT’s: Patient Evaluation Take-home points • Abnormalities of ALT and AST are common – Medications are the first thing to look

NAFLD and imagingNAFLD and imaging

• > 33% fat for detection• > 33% fat for detection• Steatosis vs NASH – no distinction

Sensitivity PPV% %

US 100 62US 100 62

CT 93 76

Saadeh, Gastro 2002

Page 18: Abnormal LFT’s: Patient Evaluation...Abnormal LFT’s: Patient Evaluation Take-home points • Abnormalities of ALT and AST are common – Medications are the first thing to look

Fatty liver

Page 19: Abnormal LFT’s: Patient Evaluation...Abnormal LFT’s: Patient Evaluation Take-home points • Abnormalities of ALT and AST are common – Medications are the first thing to look

Case # 2 : elevated ALT and AST

Page 20: Abnormal LFT’s: Patient Evaluation...Abnormal LFT’s: Patient Evaluation Take-home points • Abnormalities of ALT and AST are common – Medications are the first thing to look

Case # 2

The same 46 y/o lady now has the following lab results:

HCV ab – positiveHCV ab positive

HBV markers – negative

Page 21: Abnormal LFT’s: Patient Evaluation...Abnormal LFT’s: Patient Evaluation Take-home points • Abnormalities of ALT and AST are common – Medications are the first thing to look

Case #2

You order?:• HCV RIBA3HCV RIBA3• HCV RNA

Q lit ti– Qualitative– Quantitative

• HCV genotype• Liver biopsy

Page 22: Abnormal LFT’s: Patient Evaluation...Abnormal LFT’s: Patient Evaluation Take-home points • Abnormalities of ALT and AST are common – Medications are the first thing to look

Case #2

HCV RIBA 3 Only for neg RNA

HCV RNA qualitativequalitativeHCV RNA

i iFor prognostic and tx

quantitative purposesHCV genotype To predict response

to tx and durationLiver bx For prognosis and tx p g

Page 23: Abnormal LFT’s: Patient Evaluation...Abnormal LFT’s: Patient Evaluation Take-home points • Abnormalities of ALT and AST are common – Medications are the first thing to look

Hepatitis C: some factsHepatitis C: some facts

USA 4 illi i f d• USA: 4 million infected– general prevalence 1. 8%

i Hi i d bl k– greater in Hispanics and blacks– general prevalence in PR 2.2%

Sl l i i h i (20%?) d d• Slow evolution to cirrhosis (20%?) and end-stage liver diseaseH ll l i l• Hepatocellular carcinoma a long-termcomplication (20% of cirrhosis)M t f t f OLT i d lt• Most frequent cause for OLT in adults

Page 24: Abnormal LFT’s: Patient Evaluation...Abnormal LFT’s: Patient Evaluation Take-home points • Abnormalities of ALT and AST are common – Medications are the first thing to look

Elevated aminotransferases: the common and not-so common

• Chronic viral hepatitis• Alcoholic liver disease

• The genetic:– Hereditary

hemochromatosis• NAFLD • Drugs

hemochromatosis– Wilson’s disease– α-1 antitrypsing

– Many and any– 10% of “hepatitis”

ypdeficiency

• The rare: celiacdisease– 40% if > 40 y/o

• Autoimmune hepatitis

disease• The distractor: muscle

diseasedisease

Page 25: Abnormal LFT’s: Patient Evaluation...Abnormal LFT’s: Patient Evaluation Take-home points • Abnormalities of ALT and AST are common – Medications are the first thing to look

Abnormal enzymes: significance

• 81/1124 with negative markers:– 8 nl– 41 steatosis– 26 steatohepatitis– 4 fibrosis – 2 cirrhosis

(Amer J Gastro 1999)( )

• 99/19877 donors (recruits) – 4 HBV, 4 HCV, 2 AIH, 87 no explanation (Dig Dis Sci 1993)

Page 26: Abnormal LFT’s: Patient Evaluation...Abnormal LFT’s: Patient Evaluation Take-home points • Abnormalities of ALT and AST are common – Medications are the first thing to look

Abnormal enzymes: findings

• 149 asx – 64% fatty liver, 20% CAH/CPH, 6% cirrhosis, 4% A1ATD, 3.5% HHC , ,(Scand J Gastro 1986)

• 5/36 – change in pre-bx diagnosis – 3 NASH to nl – 1 NASH to PSC– 1 ALD to nl

(Amer J Gastro 2000)

Page 27: Abnormal LFT’s: Patient Evaluation...Abnormal LFT’s: Patient Evaluation Take-home points • Abnormalities of ALT and AST are common – Medications are the first thing to look

Elevated aminotransferases:Elevated aminotransferases: the initial tests

• HCV ab• HBsAg HBsAb HBcAbHBsAg, HBsAb, HBcAb• s Fe and TIBC

C l l i ( 40 / )• Ceruloplasmin (< 40 y/o)• s protein electrophoresis

Page 28: Abnormal LFT’s: Patient Evaluation...Abnormal LFT’s: Patient Evaluation Take-home points • Abnormalities of ALT and AST are common – Medications are the first thing to look

Case #3:Elevated Alk Phos

Page 29: Abnormal LFT’s: Patient Evaluation...Abnormal LFT’s: Patient Evaluation Take-home points • Abnormalities of ALT and AST are common – Medications are the first thing to look

Case # 3Case # 3

A 50 y/o woman has history of intermittent RUQA 50 y/o woman has history of intermittent RUQ pain for 6 months. She has now noticed dark urine for several days No significant weight loss nofor several days. No significant weight loss, no other complaints.

Physical exam shows an overweight woman in no distress, with mild jaundice.

Labs: Alk Phos – 300 , AST – 65, ALT- 70, T.Bili - 4 24.2

Page 30: Abnormal LFT’s: Patient Evaluation...Abnormal LFT’s: Patient Evaluation Take-home points • Abnormalities of ALT and AST are common – Medications are the first thing to look

Case #3

• Your next step is:• Because you think she has:y

• US – cholelithiasis CBD measures 1 5 cmsUS cholelithiasis, CBD measures 1.5 cmsand shows a stone distally

• ERCP – papillotomy and stone extractionERCP papillotomy and stone extractionperformed uneventfully followed by lapchole

Page 31: Abnormal LFT’s: Patient Evaluation...Abnormal LFT’s: Patient Evaluation Take-home points • Abnormalities of ALT and AST are common – Medications are the first thing to look
Page 32: Abnormal LFT’s: Patient Evaluation...Abnormal LFT’s: Patient Evaluation Take-home points • Abnormalities of ALT and AST are common – Medications are the first thing to look
Page 33: Abnormal LFT’s: Patient Evaluation...Abnormal LFT’s: Patient Evaluation Take-home points • Abnormalities of ALT and AST are common – Medications are the first thing to look

Case # 4:elevated Alk Phos

Page 34: Abnormal LFT’s: Patient Evaluation...Abnormal LFT’s: Patient Evaluation Take-home points • Abnormalities of ALT and AST are common – Medications are the first thing to look

Case # 4

A 50 y/o woman comes to your office because her gynecologist ordered some routine labs andher gynecologist ordered some routine labs and found an elevated Alk Phos. She has history of hypothyroidism on adequate replacemnethypothyroidism, on adequate replacemnet therapy.

Physical exam shows some palmar erythema, and a palpable liver.

Page 35: Abnormal LFT’s: Patient Evaluation...Abnormal LFT’s: Patient Evaluation Take-home points • Abnormalities of ALT and AST are common – Medications are the first thing to look

Case # 4

• Labs show:– Alk Phos - 350Alk Phos 350– T Bili - 1.0– ALT - 65ALT 65– AST - 70

Cholest 280– Cholest - 280

Page 36: Abnormal LFT’s: Patient Evaluation...Abnormal LFT’s: Patient Evaluation Take-home points • Abnormalities of ALT and AST are common – Medications are the first thing to look

Case # 4

• Your next step is:

• Results of the tests are:US l llbl dd d bil d t– US – normal gallbladder and bile duct

– AMA - 1:640• Do you biopsy?

Page 37: Abnormal LFT’s: Patient Evaluation...Abnormal LFT’s: Patient Evaluation Take-home points • Abnormalities of ALT and AST are common – Medications are the first thing to look
Page 38: Abnormal LFT’s: Patient Evaluation...Abnormal LFT’s: Patient Evaluation Take-home points • Abnormalities of ALT and AST are common – Medications are the first thing to look

Case # 5:elevated Alk Phos

Page 39: Abnormal LFT’s: Patient Evaluation...Abnormal LFT’s: Patient Evaluation Take-home points • Abnormalities of ALT and AST are common – Medications are the first thing to look

Case # 5

A 60 y/o male comes with RUQ discomfort and anorexia. He has noticed some recent constipation.

Ph i l h l d h d liPhysical exam shows an enlarged hard liver.

Labs show a Hgb of 11.3 gm%, and Alk Phos of g g ,275.

Page 40: Abnormal LFT’s: Patient Evaluation...Abnormal LFT’s: Patient Evaluation Take-home points • Abnormalities of ALT and AST are common – Medications are the first thing to look

Case # 5

• You choose this test to investigate the cause of the abnormal Alk Phos:

• US or CT?• US or CT?

Page 41: Abnormal LFT’s: Patient Evaluation...Abnormal LFT’s: Patient Evaluation Take-home points • Abnormalities of ALT and AST are common – Medications are the first thing to look
Page 42: Abnormal LFT’s: Patient Evaluation...Abnormal LFT’s: Patient Evaluation Take-home points • Abnormalities of ALT and AST are common – Medications are the first thing to look
Page 43: Abnormal LFT’s: Patient Evaluation...Abnormal LFT’s: Patient Evaluation Take-home points • Abnormalities of ALT and AST are common – Medications are the first thing to look

Elevated alkaline phosphatase: p pCauses

• Liver/biliary vs other– 5’ –nucleotidase or

• Infiltrative diseases– Sarcoidosis

GGT

• Chronic cholestasis – Other granulomatous

diseasesM t t ti li di– PBC

– Bile duct obstructionPSC

– Metastatic liver disease

– PSC– Adult ductopenia– Drug-inducedDrug induced

Page 44: Abnormal LFT’s: Patient Evaluation...Abnormal LFT’s: Patient Evaluation Take-home points • Abnormalities of ALT and AST are common – Medications are the first thing to look

Elevated alkaline phosphatase:Elevated alkaline phosphatase:what next?

AMA +AMA + Liver bx

AMAAMA –US –AP>1 5x uln

Liver bx&

AP>1.5x ulnERCP/MRCP

Page 45: Abnormal LFT’s: Patient Evaluation...Abnormal LFT’s: Patient Evaluation Take-home points • Abnormalities of ALT and AST are common – Medications are the first thing to look

Elevated alkaline phosphatase:Elevated alkaline phosphatase:what next?

US: dilated ducts ERCP

AP<1.5x uln, other tests nl Observeother tests nl

Page 46: Abnormal LFT’s: Patient Evaluation...Abnormal LFT’s: Patient Evaluation Take-home points • Abnormalities of ALT and AST are common – Medications are the first thing to look

Abnormal liver tests:Abnormal liver tests:when to refer?

• For treatment decision of chronic viral hepatitis, including biopsy

bi d f i li• For biopsy and treatment of autoimmune liver diseases

• For ERCP/MRCP when indicated• For ERCP/MRCP when indicated• For liver biopsy of chronic significantly abnormal

(>2xULN) liver tests( )• For interventional evaluation of abnormal images

(biopsy, arteriogram, etc)

Page 47: Abnormal LFT’s: Patient Evaluation...Abnormal LFT’s: Patient Evaluation Take-home points • Abnormalities of ALT and AST are common – Medications are the first thing to look

When to biopsy?When to biopsy?

Page 48: Abnormal LFT’s: Patient Evaluation...Abnormal LFT’s: Patient Evaluation Take-home points • Abnormalities of ALT and AST are common – Medications are the first thing to look

Indications for Liver Biopsy

• Diagnosis, grading and staging of alcoholic liver disease, NASH and autoimmune ,hepatitis

• Grading and staging of chronic hepatitis BGrading and staging of chronic hepatitis B and C

• Diagnosis of hemochromatosis in index• Diagnosis of hemochromatosis in index patients and relatives, quantitative iron

NEJM 2001;344:495-500

Page 49: Abnormal LFT’s: Patient Evaluation...Abnormal LFT’s: Patient Evaluation Take-home points • Abnormalities of ALT and AST are common – Medications are the first thing to look

Indications for Liver Biopsy

• Diagnosis of Wilson’s disease (quantitation of copper levels)

• Evaluation of cholestatic liver diseases PBC and PSC

• Evaluation of abnormal liver tests with negative or inconclusive serologic work-up

• Evaluation of effects of treatment regimens (ex. MTX for psoriasis)

NEJM 2001;344:495-500

Page 50: Abnormal LFT’s: Patient Evaluation...Abnormal LFT’s: Patient Evaluation Take-home points • Abnormalities of ALT and AST are common – Medications are the first thing to look

Indications for Liver Biopsy

• Diagnosis of liver mass• Evaluation of transplanted liver or donorEvaluation of transplanted liver or donor

liver• Evaluation of FUO with culture• Evaluation of FUO, with culture

NEJM 2001;344:495-500NEJM 2001;344:495 500

Page 51: Abnormal LFT’s: Patient Evaluation...Abnormal LFT’s: Patient Evaluation Take-home points • Abnormalities of ALT and AST are common – Medications are the first thing to look

Abnormal LFT’s: Patient EvaluationTake-home points

• Abnormalities of ALT and AST are common– Medications are the first thing to look for

li / f f h h– Fatty liver/NASH accounts for most of the others• Ultrasound is useful• Serious liver disease is frequently asymptomatic• Serious liver disease is frequently asymptomatic

and must be considered in the patient with abnormal liver tests

• Chronic abnormalities may warrant a liver biopsy, but change of management is infrequent

Page 52: Abnormal LFT’s: Patient Evaluation...Abnormal LFT’s: Patient Evaluation Take-home points • Abnormalities of ALT and AST are common – Medications are the first thing to look

Thank you!Thank you!


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