GI signs symptoms abnormal LFT
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| transaminases (ALT, AST,etc)are found | many tissues (liver, cardiac, skeletal muscle, kidney, brain, pancreas) |
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| transaminases: causes of elevation | acute heptocellular injury from necrosis or inflammation | do not indicate severity of liver injury
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| most common cause of elevation of transaminases | alcoholic hepatitis |
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| ALT | enzyme predominately found in liver, kidney; more specific than AST | alanine aminotransferase
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| AST | enzyme found in liver, cardiac, skeletal, kidney, brain | aspartate aminotransferase
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| ALT reference range | 20-60 IU/L |
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| AST reference range | Male:6-34 IU/L Female: 8-40 IU/L |
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| T/F: ALT and AST do not indicate the severity of liver injury. | True | They may be normal in severe disease.
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| highest levels of ALT & AST occur with these conditions | severe viral hepatitis, durg-induced liver injury, ischemic hepatitis | >500 U/L
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| moderate levels of ALT & AST occur with these conditions | mild acute viral hepatitis, chronic active hepatitis, cirrhosis, liver metastases | <300 U/L
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| mild levels of ALT & AST occur with these conditions | biliary obstruction |
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| serum liver chemistries evaluate hepatic eexcretion | bilirubin, alkaline phosphatase, gamma-glutamyl transpeptidase (GGT) |
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| degradation product of heme | bilirubin |
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| direct bilirubin | conjugated bilirubin | processed by liver
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| indirect bilirubin | unconjugated bilirubin | not processed by liver
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| bilirubin reference | direct: 0.1-0.4mg/dL total: 0.2-1.2 mg/dL |
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| enzyme found in liver, blood, urine | bilirubin |
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| elevated direct bilirubin cause & conditions | impaired excretion of bilirubin from liver; hepatocellular disease, biliary tract obstruction, drugs,sepsis |
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| elevated indirect bilirubin cause & conditions | hepatic bilirubin uptake is decreased due to drugs, heart failure; hemolysis or ineffective erythropoiesis; enzyme dificiency (neonatal jaundice) |
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| enzyme found in various tissues including liver, bone, intestine, and placenta | alkaline phospahtase |
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| elevated ALP level in the absence of bone disease or pregnancy indicate | impaired biliary tract function (cholestasis) or infiltrative liver disease, hepatic excretion |
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| GGT | enzyme found in liver,pancreas, kidney, heart, brain |
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| GGT cause of elevation | hepatic excretion |
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| 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 |
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| evaluate hepatic protein sythesis | prothrombin time & serum albumin |
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| 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 |
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| albumin | blood plasma protein synthesized in the liver |
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| decreased serum albumin | imparied hepatic protein synthesis, excess protein loss |
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| risk factors of abnormal liver function test | alcohol, drugs metabolized by liver, genetic predispostion |
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| prevention & screening related to abnormal LFT | annual evaluation of LFTs in high risk patients |
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| 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 |
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| assessment of pt with abnormal LFTs: physical exam | skin-jaundice, spider angioma, caput medusae, ecchymosis; abd-ascites, organomegaly, tenderness; extremities-asterixis, edema, muscle wasting |
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| 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 |
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| 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 |
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| caput medusae | annular purple discoloration around umbilicus or ostomy |
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| asterixis | abnormal tremor consisting of involuntary jerking movements, especially in the hands, frequently occurring with impending hepatic coma and other forms of metabolic encephalopathy |
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| best screening test to evaluate gallstones; detect biliary tree dilation, biliary obstruction, cholecystitis, fatty liver & liver parenchymal disease | abdominal ultrasound |
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| 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 |
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| can better visulaize vessels without the use of IV contrast | magnetic resonance imaging |
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| 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 |
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| defintiive test to determine cause & extent of hepatocellular & infiltrative disease; may be guided using CT or MRI | liver biopsy |
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| management of abnormal LFTs: aim | correct underlying cause |
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| management of abnormal LFTs: nonpharmacologic treatment | avoid drugs & agents that are hepatotoxic |
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| abnormal LFTs: special considerations | geriatric-higher incidence of neoplasm; pregnancy-elavated ALP common since present in placental tissues, CT CI |
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| 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 |
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| serum liver chemistries evaluate hepatic cellular integrity | alanine & aspartate aminotransferase |
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