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Path: Liver 2 - Failure (iv) (interpretation of LFTs (single…
Path: Liver 2 - Failure (iv)
interpretation of LFTs
clinical context
reason (presenting complaint)
hx
exam
isolated test abnormal or several?
magnitude of abnormality(ies)
tests within reference range don't exclude clinical disease
remember non-liver/biliary tract causes
pattern of abnormality if there are several - key part of analysis
hepatocellular damage: transaminases predominate
obstructive/cholestatic: ALP, gGT predominate
incl infiltratie liver disease + focal liver disease
always do US to excl extrahepatic duct obstruction
single isolated/unexpected abnormal
common in GP
"clinical filter"
any known risks/signs/symptoms of liver disease
found on investigation of non-specific illness or @ screening?
magnitude of abnormality?
just out of range
more than double
persistent or transient? some recommend retesting single mildly abnormal results after a few months
concern: miss txable disease
go back on hx (alcohol, drugs, obesity, DM, virus) + exam
initial work up if liver disease possible/likely
possibly more blood tests (viral serology, iron stage status, AI) + US
obstructive/cholestatic pattern of abnormal LFTs
infiltrative disease: diffuse processes - sarcoid, amyloid, lymphoma
metastatic disease in liver may cause local obstruction or diffuse infiltration
intraheptiac cholestasis
chronic AI (PSC, PSC)
drugs
pregnancy
sepsis
rare inherited conditions
extrahepatic cholestasis
stone
stricture
tumour
liver imaging
US: dilated ducts, gallstones, focal liver lesions, liver texture (echogenicity), liver border (inhomogeneity), not sensitive for cirrhosis or mild fatty change
MRCP (magnetic resonance choledochopancreatography)
CT/MRI (each +/- contrast enhancement)
endoscopic US (EUS)
ERCP (endoscopic retrograde choledochopancreatography)
biliary tract outlined in retrograde fashion by contrast introduced @ ampulla via endoscope
diagnostic with therapeutic intent (tx CBD stone, drain biliary tract, stand obstruction)
Percut transhepatic cholangiography (PTC) - decompression/visualisation of obstructed biliary system
liver biopsy
indications
diffuse liver disease
dx cause
grade necro-inflamm activity
stage fibrosis
! sampling variability
focal liver lesion
cyst
haemangioma
tumour (benign, malignant, primary, secondary)
tumour-like
not always: US, CT, MRI + context usually diagnostic
for cytology
approaches
Percut (radiological guidance, needle core of tissue)
transjugular (if coagulopathy )
laparoscopic (for focal lesion)
risks
pain
bleeding
bile leakage
trauma
2-3% hospitalised
1/10 000 mortality
contraindications: clotting problems, anti-clotting drugs, biliary obstruction
balance risks vs benefit - will it affect tx or prognosis?
beforehand do platelet count, coag screen, blood group
preformed less now
standard handling in lab: H+E + routine "special stains" for fibrosis + iron
Non-invasive assessment of liver fibrosis
serum markers
APRI (AST PT ratio index)
NAFLD fibrosis score
proprietary (fibrotest - EFS)
transient elastography (FibroScan)
measures liver stiffness
US assessment of velocity of elastic shear wave signal
best @ identifying ends of spectrum