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FNP Review 9

GI signs symptoms abnormal LFT

QuestionAnswerRationale
transaminases (ALT, AST,etc)are found many tissues (liver, cardiac, skeletal muscle, kidney, brain, pancreas)
transaminases: causes of elevation acute heptocellular injury from necrosis or inflammation do not indicate severity of liver injury
most common cause of elevation of transaminases alcoholic hepatitis
ALT enzyme predominately found in liver, kidney; more specific than AST alanine aminotransferase
AST enzyme found in liver, cardiac, skeletal, kidney, brain aspartate aminotransferase
ALT reference range 20-60 IU/L
AST reference range Male:6-34 IU/L Female: 8-40 IU/L
T/F: ALT and AST do not indicate the severity of liver injury. True They may be normal in severe disease.
highest levels of ALT & AST occur with these conditions severe viral hepatitis, durg-induced liver injury, ischemic hepatitis >500 U/L
moderate levels of ALT & AST occur with these conditions mild acute viral hepatitis, chronic active hepatitis, cirrhosis, liver metastases <300 U/L
mild levels of ALT & AST occur with these conditions biliary obstruction
serum liver chemistries evaluate hepatic eexcretion bilirubin, alkaline phosphatase, gamma-glutamyl transpeptidase (GGT)
degradation product of heme bilirubin
direct bilirubin conjugated bilirubin processed by liver
indirect bilirubin unconjugated bilirubin not processed by liver
bilirubin reference direct: 0.1-0.4mg/dL total: 0.2-1.2 mg/dL
enzyme found in liver, blood, urine bilirubin
elevated direct bilirubin cause & conditions impaired excretion of bilirubin from liver; hepatocellular disease, biliary tract obstruction, drugs,sepsis
elevated indirect bilirubin cause & conditions hepatic bilirubin uptake is decreased due to drugs, heart failure; hemolysis or ineffective erythropoiesis; enzyme dificiency (neonatal jaundice)
enzyme found in various tissues including liver, bone, intestine, and placenta alkaline phospahtase
elevated ALP level in the absence of bone disease or pregnancy indicate impaired biliary tract function (cholestasis) or infiltrative liver disease, hepatic excretion
GGT enzyme found in liver,pancreas, kidney, heart, brain
GGT cause of elevation hepatic excretion
T/F: GGT is highly sensitive indicator of acute alcohol ingestion & other agents that stimulate hepatic microsomal oxidase system such as barbiturates and phenytoin. True
evaluate hepatic protein sythesis prothrombin time & serum albumin
prolonged PT impaired hepatic synthesis of coagulation factors seen in signifcicant liver disease and/or vitamin K deficiency that occur with malnutrition, malabsorption (cholestasis, steatorrhea, pancreatic insufficiency) & warafin use
albumin blood plasma protein synthesized in the liver
decreased serum albumin imparied hepatic protein synthesis, excess protein loss
risk factors of abnormal liver function test alcohol, drugs metabolized by liver, genetic predispostion
prevention & screening related to abnormal LFT annual evaluation of LFTs in high risk patients
assessment of pt with abnormal LFTs: history General-fever, anorexia, weight loss, jaundice, arthralgia; GI-N/V, abd pain, dark urine, pale stools; risk factors-hepatitis, gallstone,transfusion, alcohol/drug use
assessment of pt with abnormal LFTs: physical exam skin-jaundice, spider angioma, caput medusae, ecchymosis; abd-ascites, organomegaly, tenderness; extremities-asterixis, edema, muscle wasting
assessment of pt with abnormal LFTs: diagnostic studies (asymptomatic) repeat LFT first; if normal, repeat testing in 3-6 months; if repeat abnormal, obtain hepatitis serologies
assessment of pt with abnormal LFTs: diagnostic studies (symptomatic) guided by H&P; consider: mono spot & CMV IgG, IgM titers, abd US, CT with IV contrast, MRI, ERCP, liver biopsy
caput medusae annular purple discoloration around umbilicus or ostomy
asterixis abnormal tremor consisting of involuntary jerking movements, especially in the hands, frequently occurring with impending hepatic coma and other forms of metabolic encephalopathy
best screening test to evaluate gallstones; detect biliary tree dilation, biliary obstruction, cholecystitis, fatty liver & liver parenchymal disease abdominal ultrasound
best test to evaluate liver parenchymal disease & space occupying lesions (tumor or abscess); can also assess biliary tree dilation & identify obstructing lesion computed tomography scan with IV contrast
can better visulaize vessels without the use of IV contrast magnetic resonance imaging
usually done after screening with US, CT or MRI to further assess cause, location & extenet of biliary tree abnormalities endoscopic retrograde cholangiopancreatography; percutaneous transheptic cholangiography
defintiive test to determine cause & extent of hepatocellular & infiltrative disease; may be guided using CT or MRI liver biopsy
management of abnormal LFTs: aim correct underlying cause
management of abnormal LFTs: nonpharmacologic treatment avoid drugs & agents that are hepatotoxic
abnormal LFTs: special considerations geriatric-higher incidence of neoplasm; pregnancy-elavated ALP common since present in placental tissues, CT CI
abnormal LFTs: when to consult, refer or hospitalize consult/refer-significantly abnormal LFTs persist without identifiable cause or symptomatic patients in need of special test and management
serum liver chemistries evaluate hepatic cellular integrity alanine & aspartate aminotransferase
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