Jan 3, 2020
In the first of two podcasts, Dr. Tara McMichael, a board certified Internist with Lakeview Clinic, and hospitalist with Ridgeview Medical Center, discusses liver function tests, and presents a few cases she has seen in her practice.
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Dr. Tara McMichael is joining us today, who is a board certified internist with Lakeview Clinics, as well as a hospitalist at Ridgeview Medical Center. She did her internal medicine residency at Abbott Northwestern Hospital in Minneapolis. Today, we will discuss abnormal liver tests. What to do with them and what's causing them.
In the first of two podcasts, Dr. McMichael will walk through a few cases she has seen in her practice. First, she's going to give us an overview, though, about liver "function" tests. So ditch the parka, come in from the cold and hop on that rowing machine you've been resolving to use again. It's time for Ridgeview podcast, CME series with Dr. Tara McMichael.
A quick recap on the overall approach to abnormal liver tests. The name liver "function tests" is a bit of a misnomer. Many of these transaminase tests are actually liver biochemistries or more simply, liver tests, as opposed to an actual "function test" of the liver. PT/INR and albumin are more accurately termed "function tests", because they are a true proxy for the functional status of the liver. These tests are ordered frequently, and often come back somewhat abnormal in otherwise healthy or asymptomatic people. In our medical system, the online subscription health reference, UpToDate, is used, and it turns out this is one of the most commonly searched topics. While the tests are commonly ordered, they are not supposed to be part of routine screening in the otherwise healthy patient. In general, these are tested for in symptomatic patients, or if patients are on certain medications that can cause liver damage.
The AGA and the ACG have specific guidelines for testing liver serologies. If tests come back mildly elevated, in other words, two times upper normal or less, the tests should be rechecked in 2-to-4 weeks. If not escalating in that amount of time, they can be rechecked in 6-months. If there is escalation, referral to GI is appropriate. Checking LFTs is appropriate if taking statins, INH, methotrexate and the like. Social history is also important, besides alcohol. Travel, occupational and recreational exposure (i.e. drug abuse). Stay tuned as Dr. McMichael launches into her first liver case.
64-yo male with 10 days of diarrhea, nausea, fevers and chills. He claims to not drink "too much". Diarrhea increases over the course of the illness and the temp has gone to 100.8. Oh, by the way, some old cephalexin laying around at home seemed like a good idea to the patient, so he began taking it. No better or worse with this. It turns out, after further teasing, he drinks 7 to 10 drinks in a setting. PMH includes HTN, DM type-2, hyperlipidemia and chronic LE edema with recurrent cellulitis. Also has psoriasis with psoriatic arthritis. He's obese and a non-smoker. Meds include baby ASA, vit D, methotrexate for the past 5-years, cephalexin preventatively and lisinopril. His social and family hx is unremarkable. Vital signs are unremarkable, and his overall appearance and exam is unremarkable. Except that he has a protuberant abdomen, a BMI of 37 (morbidly obese), and an unchanged swollen left lower limb. Labs were done: CMP, CBC, CRP, sed rate, blood cultures and a chest x-ray. Chest x-ray was unremarkable. However, lab work revealed the following positives; AST slightly up at 59. ALT normal. ALP 148, also slightly elevated. Total bili elevated and low total protein was also noted. Remember that direct bilirubin is conjugated bilirubin. It is conjugated in the liver. And when it is high enough, it spills into the urine. Indirect is actually found more often than direct. Such as Gilbert and hemolysis. Thus far we are thinking acute gastroenteritis. These are mildly elevated LFTs after all. However, in follow-up, Treatment so far includes hydration, and possibly testing the stool for enteric pathogens. Hepatitis seems unlikely due to minimally elevated LFTs. One must also consider his likely underreported alcohol intake. But what about his methotrexate? No imaging was done in the preliminary work up. His symptoms progressively improved. Repeat LFTs are done in a follow-up about 10-days later. His AST, ALT, ALP and bili are all just a little bit more now. Albumin is also a little lower now. He does drink while continuing to take methotrexate.
NASH or NAFLD are synonymous. Non-alcoholic steatohepatitis and nonalcoholic fatty liver disease. Liver biopsy at this point is the gold standard, however, there are non-invasive options that some hepatologists employ, such as fibroscan and elastography. Coupled with abnormal labs and history, the liver biopsy may in some cases be averted. In our patient, and abdominal ultrasound was performed, that reveals hepatomegaly, mild ascites and a coarsened liver parenchyma that is suspicious for cirrhosis. In addition, this patient also has a liver biopsy that reveals cirrhosis, and not NAFLD. What exactly is cirrhosis? It is the late stage of progressive liver fibrosis. It can be reversible in its earlier presentation, but is not reversible in its more advance stages. Alcohol, but also as we will find out, other factors can cause this. Cirrhosis from all causes comprises 80% of the liver transplant list. In our patient, Is he drinking too much? Probably. But there may be other factors. Regarding alcohol, 210 grams or 15 standard sized drinks for a male per week is considered significant alcohol intake and for women 140 g or 10 standard drinks per week. Be sure to specify with patients what their standard pour is per drink. Is it a 12 oz beer or 40 oz beer, etc.
Other labs are helpful as well in cirrhosis in terms of monitoring and diagnosis. These patients are often hyponatremic, due to impaired ADH and thrombocytopenic due to sequestration of platelets as opposed to decreased production. AST is typically twice the value of the ALT, although you may also see this in NAFLD. In this patient, there is probable interplay between alcohol and methotrexate. We must also think about Hepatitis B and C. So hepatitis serologies are important. Autoimmune hepatitis, Wilson's disease, hemochromatosis (think family history here), right heart failure, hepatorenal syndrome, primary biliary sclerosis and primary sclerosing cholangitis should be considered. Other important physical findings can include palmar erythema, limb atrophy, telangiectasias, caput medusa (prominent veins on a protuberant abdomen) and gynecomastia.
Dr. McMichael prefers to refer these patients to GI and hepatology earlier than later. Often a tertiary center where they can be comanaged. The MELD score of MELD sodium score is a compilation of criteria that predicts the 3-month mortality rate in end stage liver disease. This helps the hepatologist or intensivist to determine when to consider putting the patient on the transplant list. Going back to drugs causing liver damage, there are literally hundreds of possible culprits. Supplements as well. Some of these drugs and supplements include statins, INH, methotrexate, aminodarone, various antibiotics, black kohash, wild mushrooms, weight reduction medications, antifungals and many others. Cirrhosis is associated with a lot of stigma, so take this into consideration when approaching the diagnosis in your patients. Remember, while it is often is the alcohol, there may be other issues causing this disease process.
Hopefully this podcast was helpful and informative. Cirrhosis is an all too common problem. Again liver test abnormalities can be subtle, and the cause is not always just alcohol. The life expectancy in compensated cirrhosis is 12-years or more, but uncompensated cirrhosis is less than 6-months. This would involve complications like variceal bleeding, ascites, hepatorenal syndrome, hepatocellular carcinoma, SBP and hepatopulmonary syndrome.
That's all for now, folks! Be sure to tune into Abnormal Liver Tests - Part 2 with Dr. McMichael.