Jan 3, 2020
In this second part of the Abnormal Liver Function Test podcast series, Dr. Tara McMichael continues her discussion and case presentation around abnormal liver function tests.
Enjoy the second part of the "Abnormal Liver Function Test" podcast!
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69 yo female with 2 days of low back pain. Also some dark urine for about a week. She has some fatigue as well. No jaundice or bowel changes. She's not much of a drinker, minimal wine. PMH incudes obesity, hyperlipidemia and a prediabetic state. She take vitamins, calcium and glucosamine. No drugs and no significant family history. She's had about a 10 lb unintential weight loss. Also some early satiety. Her BMI is 32, but otherwise her VS and entire exam is normal. Additionally, she's been taking aspirin for her back pain. Laboratory eval reveals AST of 767, ALT 818, and ALP 173. These are all modestly to significantly elevated. The AST and ALT are over 4 times upper limit of normal. Basically she's not really ill appearing at this point. Differential diagnosis at this point includes acute viral hepatitis. We must consider testing for A, B, C as well as EBV and CMV. These are IgM and IgG studies typically. Billiary obstruction and cirrhosis seems less likely in this case. Also not likely ETOH related. NASH is a possibility. We should also review her meds as a potential cause. Was she actually taking aspirin, or is she just calling it aspirin. Let's not forget some of the less common diseases like autoimmune hepatitis, Wilson's hemochromatosis and other rare infections. Right-sided heart failure may be an option. Hepatitis serologies, EBV, CMV, Tylenol level, iron and copper levels, ESR as well as PT/INR would be appropriate. CRP was a bit elevated at 11. Gamma globulins are obtained and noted to be elevated. The rest of the labs were all normal as well. A liver ultrasound reveals no abnormalities. A GI consult was obtained and it was felt this is a case of autoimmune hepatitis. Typically this is a dx of exclusion, and now that we've excluded a lot, we will shift to various autoimmune tests. ANA. This may be positive, however there are more specific tests for this condition, such as anti-smooth muscle, antimitochondrial, and anti liver-kidney microsomal antibodies, and various other antibody tests. Gamma globulins are also often elevated in AIH What is this condition? We don't fully know. There are several types of autoimmune hepatitis, however type-1 is the most common. It is actually not an entirely uncommon disease with a prevalence in Europe of 11 to 25 per 100,000. In the U.S., there is no exact data. One could infer that it would be similar. Ultimately, the body is attacking the liver for unclear reasons. Concurrent autoimmune thyroiditis can accompany this. A known hx of inflammatory bowel dz can predispose to this condition. Typically AST and ALT are 10-20 times upper limits of normal, usually therefore much higher than cirrhosis. Imaging is usually normal, unless the disease has advanced by the time diagnosis is made. Remission is not uncommon, upwards of 50 to 60%. Corticosteroids and azathioprine are common medications given for this. These can be tapered, and LFTs are rechecked on a regular basis throughout the taper and discontinuation of the medications. Sometimes, stronger immunosuppressants are needed. GI at minimum but sometimes hepatology referral is warranted for this diagnosis. Liver biopsy is often done for this condition. And indeed was on this patient which showed findings consistent with autoimmune hepatitis. Often, a degree of fibrosis is seen in AH.
Well people, that's a wrap. for autoimmune hepatitis. Stay tuned for the final case presentation in the next segment, coming up shortly with Dr. McMichael here on Ridgeview Podcast CME series.
So, the final caser is an 80 yo male with fever and confusion. He's high functioning at baseline, lives alone at home. He called his daughter and she noted he wasn't "acting himself". Altered mental status can be caused by many things, as we know. The differential diagnosis includes infection, hypoxia, metabolic derangement, toxin related, dementia, CNS lesions and so many more! This guy has a hx of CLL and type 2 DM, as well as HTN and BPH. Not a big drinker, about 1 to 2 beverages per day. He has a fever of 100.8. VS are normal otherwise. He's uncomfortable and restless appearing. Alert and oriented to person. Sepsis now is a big concern. What's causing it? He still has a gallbladder, but we need to know some more about his exam reveals not much more, other than tenderness in the epigastric and LUQ areas of the abdomen.
Preliminary labs include normal UA, EBC 35.8, but remember the cLL hx. BMP unremarkable but a little dry with BUN 32. ALP is 256. AST and ALT are just bumped over normal. Lipase and trop are normal. Total bili is normal. So probable not ascending cholangitis. CXR was normal. So prompted a CT abdomen to rule out abdominal pathology. This revealed cholelithiasis. Compared to ultrasound, CT is not as helpful in terms of ruling out biliary obstruction, although often we will see pericholecystic inflammation. For cases of acute cholecystitis (AC), CT scan findings include the following: gallstones within the gallbladder (GB), the cystic duct, or both; more than 3mm of focal or diffuse thickening of the GB wall in a non-contracted GB; indistinct liver-GB interface; fluid in the GB fossa in the absence of ascites, enlargement of the GB, with the transverse diameter measuring more than 5 cm; infiltration of the surrounding fat; increased bile attenuation, caused by biliary sludge; and GB mucosal sloughing. At the same time, ultrasound is the gold standard. So this was done, and antibiotics were ordered. There is a non-mobile gallstone in the gallbladder neck. The CBD also has a small distal stone. He was admitted, taken to surgery for lap cholecystectomy and cholangiogram which confirmed the distal CBD stone. He was taken for ERCP and stenting the next day. In cholestatic presentations, the ALP is usually higher than AST and ALT. Serum bilirubin is not as helpful in delineating hepatocellular vs cholestatic picture. The Tokyo guidelines? Not widely used at this point. They're used to grade who needs to go to surgery first. In general, it's recommended to follow the American Anesthesiology guidelines for physical status. There are several grading systems, but there is little banter about this when it comes down to the decision to go to surgery or not. According to a paper in 2017 in the American Journal of Surgery by Madni et al, "Most grading scales which have been developed are used to predict the risk of conversion to an open cholecystectomy. There is a paucity in the literature of scoring systems to predict other metrics such as hospital length of stay, iatrogenic injury, and total operative time."
HIDA scan can be done if there is no obvious stone, and whether you think this is truly gallbladder dysfunction and the patient should go to surgery, according to the World Society of Emergency Surgery Guidelines. Now, if this were a woman child-bearing age, while there could be a gallbladder etiology, always be sure to check a pregnancy test. HELLP syndrome must be considered. Fitz Hugh Curtis syndrome should also be considered in sexually active women with abdominal pain and elevated LFTs. Remember, especially in patients with altered mental status to keep your net cast wide. Our elderly patients are notorious for unusual presentations of common disease. Just a fair warning.
A special thanks to Dr. McMichael for joining us and sharing these cases today. Have a great month everyone and we'll see you soon.
1. D'Amico et al. J Hepatology, 2006, Natural History and Prognostic Indicators in Cirrhosis: A systematic review
2. Salpeter et al. Am J Med. 2012. Systematic Review of Noncancer Presentations with a median survival of months or less.
3. Wond et al, Gastroenterology, 2015. Nonalcoholic Steatohepatitis is the second leading cause of liver disease in adults awaiting liver transplantation in the United States.