Abnormal LFTs in Adults Abnormal LFTs Liver disease

Abnormal LFTs in Adults

Abnormal LFTs �Liver disease is often asymptomatic �Deranged LFTs may be the only sign of a serious underlying liver disease �Or they may be nothing wrong!

Hyperbilirubinaemia � Slight increases in bilirubin (17 -30 µmol/L) common & usually not clinically significant. � Checking conj/unconj (direct/indirect) bilirubin is seldom required in adults, unless isolated raised bilirubin (i. e. normal liver enzymes) � Causes of isolated hyperbilirubinaemia Unconjugated Conjugated Gilbert’s syndrome (usually < 70 µmol/L) Drugs e. g. phenothiazines, sulfonamides and carbimazole Stress/fasting Dubin-Johnson syndrome Drugs e. g. rifampicin, sulfonamides Rotor syndrome Haemolytic disease

Hyperbilirubinaemia

Transaminases (ALT, AST) � ALT: mostly liver specific � AST: expressed in liver cells, skeletal muscle, kidneys, brain, RBCs � ALT <120 iu/L: generally considered mild; >120 iu/L: severe � AST: ALT ratio > 2. 1 may be suggestive alcohol related liver disease � AST: ALT ratio < 2. 1 may suggest hepatic steatosis or chronic viral hepatitis � Causes of raised transaminases: Common Rarer Non-hepatic Alcohol Autoimmune hepatitis Coeliac disease Steatosis Haemachromatosis Strenuous exercise Viral Hepatitis Alpha-1 -antitrypsin defic Muscle disease Medications/toxins Wilson’s disease Endocrine (e. g. hypo/hyperthyroid

Raised ALT

Alkaline Phosphatase � The two main sources of ALP are liver and bone, although there also intestinal and placental isoforms. � Causes of raised ALP: Physiological Pathological Third trimester of pregnancy Bile duct obstruction Adolescents, due to bone growth Primary biliary cirrhosis Benign, familial Primary sclerosing cholangitis Drug induced cholestasis, e. g. anabolic steroids, COCP Metastatic liver disease Bone disease, e. g. Pagets Heart failure

Gamma Glutamyl Transferase (g. GT) �γGT : v sensitive marker for hepatobiliary disease, but its use is limited by poor specificity. (Causes include hepatobiliary disease (often with other liver enzyme abnormalities), pancreatic disease, alcohol, COPD, Renal failure, Diabetes, IHD, Drugs, e. g. carbamazepine, phenytoin and barbiturates and oral contraceptive pill) �Main role of g. GT is to support a hepatobiliary source for other liver enzymes �If isolated raised γGT: rpt bloods after 3 m if <5 x ULN; consider USS if >5 x ULN;

Raised ALP

Deranged LFTs - history �PMH: diabetes, hyperlipidaemia, obesity, autoimmune conditions �Medications �Alcohol Consumption �Occupational exposure to toxins �Family history of liver disease, autoimmune conditions �Risk factors for viral hepatitis: � intravenous drug use � travel history � non-sterile ear or body piercing � tattoos � health care intervention in developing nations � country of birth

Liver screen � Liver Ultrasound � AST � γGT � Immunoglobulins � CK � Ferritin � TFTs � Fasting Lipids � Glucose / Hb. A 1 c � Coeliac Serology � Hepatitis serology (HBs. Ag, anti-HCV Abs) � Liver Autoantibodies � Alpha-1 -antitrypsin � Caeruloplasmin (if < 50 y)