Gih Week 2: Liver Function Tests

Front 1

Which enzymes are mainly elevated in Hepatocellular disease?

Back 1

AST, ALT

Front 2

When enzyme is mainly elevated in Cholestatic disease?

Back 2

ALP
(alkaline phosphatase)

Front 3

T or F.

ALT, AST, and ALP are always elevated in the presence of liver disease.

Back 3

FALSE

ALT, AST, and ALP may be normal even in the presence of liver disease

Front 4

Where are transaminases located, and when are they released?

Back 4

Located in hepatocytes
Released after hepatocellular injury

Front 5

Which transaminase is non-specific to the liver?

Which other tissues is this enzyme located in?

Back 5

AST

Heart, skeletal muscle, blood

Front 6

Which transaminase is more specific to the liver?

What other conditions may result in elevated levels of this enzyme?

Back 6

ALT

Myopathies

Front 7

Very high transaminase elevations (>1000) are indicative of what sort of conditions?

Back 7

Acute toxic injury (tylenol, ischemia)
Acute viral disease

*Very high elevations are unlikely to be alcohol-related

Front 8

List 3 examples of alcohol-related liver diseases that would result in mild transaminase elevations.

Which transaminase will be predominant?

Back 8

1. Alcohol liver disease
2. Steatosis
3. Cirrhosis

*AST predominant

Front 9

Which transaminase is specifically seen in higher elevations in alcohol related liver diseases?

Back 9

AST

Front 10

Will alcohol related liver diseases result in mild or marked transaminase elevations?

Back 10

Mild elevations

(High elevations are associated with acute toxic injury or acute viral diseases)

Front 11

List 4 examples of non-hepatic conditions that could result in mild transaminase elevations.

Back 11

1. Hemolysis
2. Myopathy
3. Thyroid disease
4. Strenuous exercise

Front 12

What would you expect the AST:ALT ratio to be in alcoholic diseases?

How high would you expect the elevation to be?

Back 12

2:1 (AST:ALT)

AST should be <500, if it is >500 consider another cause

Front 13

If AST >500 and the patient does not use alcohol, what disease this elevation most likely indicate?

Back 13

Cirrhosis

Front 14

What AST:ALT ratio is considered "mild" transaminitis?

Back 14

AST:ALT < 5 x upper limit of normal

Front 15

What type of AST/ALT ratio would you expect to find in chronic Hep C or Hep B?

Back 15

AST/ALT <5 x upper limit of normal

Front 16

Which transaminase predominates in chronic, non-alcohol related hepatic diseases?

Back 16

ALT

Front 17

What would you expect the ratio of AST/ALT to be in Non-Alcoholic Steatohepatitis (NASH)?

Back 17

AST/ALT <1

Front 18

What would you expect the AST/ALT and MCV (mean cell volume) ratios to be in alcoholic liver disease?

Back 18

AST/ALT >2
MCV >94

Front 19

What are some clinical signs that are associated with alcoholic liver disease?

Back 19

1. Anorexia
2. Fever
3. Jaundice
4. Hepatosplenomegaly

Front 20

Which form of hepatitis is only acute (does not progress to chronic illness)?

Back 20

Hepatitis A

Front 21

Which form of Hepatitis usually doesn't present acutely--mostly chronic presentations?

Back 21

Hepatitis C

*Usually goes undetected in acute phase

Front 22

Which form of Hepatitis often presents acutely and can progress to chronic hepatitis?

Back 22

Hepatitis B

Front 23

How can you diagnose Hepatitis A?

Back 23

Presence of IgM Anti-HAV

Front 24

In general, which form of Hepatitis will present the most acutely? (matter of weeks)

Back 24

Hepatitis A
(usually presents < 1 month after exposure)

*Acute Hepatitis B takes longer to present)

Front 25

Which Hepatitis is usually spread via fecal-oral transmission?

Back 25

Hepatitis A

Front 26

How is Hepatitis B transmitted?

Back 26

Blood transfusions or sexual transmission

*Hep B has highest risk of sexual transmission out of Hep A, B, and C

Front 27

Which individuals are most likely to experience severe symptoms with acute Hepatitis B? (children or adults)

Back 27

Adults

(Children are less likely to experience severe symptoms of acute Hepatitis B, but are more likely to develop chronic Hepatitis B)

Front 28

How can you diagnose acute Hepatitis B?

Back 28

Presence of:
IgM Anti-HBc
HBSag

Front 29

Which antibodies would you expect to find in resolved Hepatitis B?

Back 29

HBcAb IgG
HBsAb

Front 30

Which antibody can be detected in an HBV vaccinated individual?

Back 30

HBSAb

Front 31

Which antibodies/antigens can be detected in a person with chronic HBV?

Back 31

HBSAg
HBcAb IgG

Front 32

How long does it usually take to start making Anti-HCV antibodies?

Back 32

70 days

Front 33

Is Hemochromatosis autosomal dominant or recessive?

Back 33

Autosomal recessive
(mutation of HFE gene)

Front 34

With hemochromatosis, what would you expect the transferrin saturation, ferritin, and genetic testing results to reveal?

Back 34

Transferrin saturation >50%
Ferritin >200
Genetic testing C282Y/C282Y

Front 35

Which autoantibodies are tested for to diagnose Autoimmune Hepatitis?

Back 35

ANA or ASMA (titer 1:80 or greater)

(IgG will also be elevated >1.5 x normal level)

Front 36

Which disease is autosomal recessive and causes a dysfunction in copper metabolism?

What are some of the clinical features of this disease?

Back 36

Wilson's disease

Signs:
1. Neuropsychiatric disease
2. Hemolytic anemia

Front 37

Which disease would show elevated urinary copper and decreased ceruloplasmin?

Back 37

Wilson's disease

Front 38

How does alpha-1 antitrypsin deficiency result in liver disease?

How does it cause lung disease?

Back 38

liver --> Accumulation of variant A1At in hepatocytes

lung--> inadequate protease inhibitor activity

*Typically presents as neonatal hepatitis

Front 39

Alkaline phosphatase is produced by what cells?

Is this enzyme specific or non-specific to the liver?

Back 39

Biliary epithelial cells

Non-specific to the liver
(also found in bone, intestine, placenta)

Front 40

What is the female:male ratio in primary biliary cirrhosis?

Back 40

9:1 (female:male)

Front 41

Which autoantibody is assocated with primary biliary cirrhosis?

Which enzyme will be elevated?

Back 41

AMA (titer 1:80 or greater)
ALP elevated

*Primary biliary cirrhosis is a cholestatic liver disease

Front 42

Biliary duct obstructions can occur due to elevations of which enzyme?

Back 42

ALP

Front 43

Which cholestatic liver disease results in inflammation of the large bile ducts and is often associated with IBD?

Would you expect an elevation of any autoantibodies or antibodies?

What enzyme will be elevated?

Back 43

Primary Sclerosing Cholangitis

No autoantibodies, no elevated globulins

Elevated ALP

Front 44

Which cholestatic liver disease has a 10-15% lifetime risk of cholangiocarcinoma?

Back 44

Primary Sclerosing Cholangitis

Front 45

Which form of bilirubin is elevated as a result of hemolysis, Gilbert syndrome, or certain medications?

Back 45

Unconjugated (indirect)

Front 46

Which form of bilirubin is elevated as a result of an obstruction, cholestasis, cirrhosis, hepatitis, etc.?

Back 46

Conjugated (direct)

Front 47

What are the 2 common symptoms seen in primary biliary cirrhosis?

Back 47

Pruritis and fatigue

Front 48

Which medication is a frequent culprit of drug-induced liver disease?

Back 48

Acetaminophen (Tylenol)

Front 49

Besides ALT, AST, and ALP, what other liver labs could you run to tell how much damage has occurred?

Back 49

1. Albumin (poor marker--also decreased by trauma, inflammatory conditions, malnutrition)
2. Prothrombin time (insensitve; no change until liver loses 80% capacity)
3. Ammonia (contributor to encephalopathy)

Front 50

At what levels are ALT and AST normally found in the serum?

Back 50

<30 to 40 U/L

Front 51

An isolated elevated AST (normal ALT levels) is usually reflective of what type of disease?

Back 51

Cardiac or muscle disease

Front 52

What kind of transaminase levels would indicate a pyridoxal 5-phosphate deficiency?

Back 52

AST/ALT > 2
(same ratio as in ETOH liver disease)

*ALT levels are low b/c ALT synthesis requires pyridoxyl phosphate more than AST synthesis does.

Front 53

What is the likely diagnosis of a patient with ALT:LDH ratio <1.5?

Back 53

Ischemic hepatitis
(more likely than acute viral hepatitis)

Front 54

What levels of ALP would you expect to find in a female patient late in pregnancy?

Back 54

levels may be 2 x normal

Front 55

If ALP and GGT are both elevated, what type of injury has most likely taken place?

Back 55

Most likely injury of hepatic origin and cholestasis at some level.

Front 56

Would you expect high or low ALP levels as a result of hyperthyroidism, lymphoma, and hypernephroma?

Back 56

High ALP

Front 57

What levels of ALP would you expect to find in children?

Back 57

Levels up to 3x normal

Front 58

What sort of levels of ALP would you expect to find as a result of hypothyroidism, Wilson's disease, or hemolysis?

Back 58

Low ALP

Front 59

Is GGT sensitive or specific for hepatobiliary disease?

Back 59

Very sensitive, but poor specificity

Front 60

What is GGT used primarily for?

Back 60

To confirm hepatic origin of elevated ALP

Front 61

What type of bilirubin do direct and indirect approximate?

Back 61

Direct--> conjugated bili
Indirect --> unconjugated bili

Front 62

More than 80% of bilirubin is indirect or direct?

Back 62

Indirect

Front 63

Increased bilirubin production will result in what type of hyperbilirubinemia?

Back 63

Unconjugated

Front 64

List 3 causes of Unconjugated hyperbilirubinemia.

Back 64

1. Increased bilirubin production
2. Decreased hepatocellular uptake
3. Decreased conjugation