Alcohol and Abnormal Alcohol and Abnormal Blood TestsBlood Tests

Dr Steve Brinksman

Dr Martyn Hull

Normal LiverNormal Liver

CirrhosisCirrhosis

AnatomyAnatomy

Liver EnzymesLiver EnzymesTransaminases ASTALT

Cholestatic EnzymesGGTAlk Phos

Additional TestsAdditional TestsAlbumin

Clotting

MCV

Transaminases

•AST and ALT are transaminases. They are associated with inflammation and/or injury to liver cells, a condition known as hepatocellular liver injury. Damage to the liver typically results in a leak of AST and ALT into the bloodstream.

AST is found in many other organs besides the liver: kidneys, muscle and the heart,

A high level of AST does not always (but often does) indicate that there is a liver problem. E.g. vigorous exercise may elevate AST levels.

ALT is found primarily in the liver, high levels of ALT almost always indicate that there’s a problem with the liver.  Conversely, a normal ALT level does not necessarily mean that the liver is definitely normal

•High levels of transaminases don’t always reveal the level of liver is damage but they are a marker of acute inflammation.

•These blood tests measure inflammation and damage to the liver at an isolated point in time.

•Recent inflammation may raise them even if no significant underlying damage conversely even with severe underlying liver damage they may be normal.

    

•The ratio of ALT to AST may also provide useful information - most liver diseases  are characterized by greater ALT elevations than AST elevations however there are two main exceptions. Both cirrhosis and/or alcohol abuse are associated with higher AST levels  than ALT levels, often in a ratio of approximately 2:1.

•Elevations of the transaminases occur due to so many causes that they give the only a vague clue of the diagnosis. Additional testing is required in order to determine more precisely what is wrong with the liver.

•GGT Gamma Glutamyl Transpeptidease and AP Alkaline Phosphatase

•High levels of GGT and AP hint at a bile duct problem either blockage or injury or inflammation.

•This is caused by an impairment, or failure, of bile flow, which is known as cholestasis. This type of liver injury is known as cholestatic and this type of liver disease is known as cholestatic liver disease. •.

Intrahepatic cholestasis refers to bile duct blockage or injury within the liver. Intrahepatic cholestasis may occur in people with primary biliary cirrhosis, alcoholic damage or liver cancer, for example.

Extrahepatic cholestasis refers to bile duct blockage or injury occurring outside the liver. Extra hepatic cholestasis may occur in people with gallstones

•When a blockage or inflammation of the bile ducts occurs, the GGT and AP levels increase and raise the blood level. These enzymes typically become markedly elevated—many times the upper limit of normal.

•GGT is found predominantly in the liver. AP is mainly found in the bones and the liver but can also be found in many other organs,e.g. the intestines, kidneys, and placenta. Elevated levels of AP will usually indicate that something is wrong with the liver only if the amount of GGT is raised as well.

GGT can be elevated without AP being elevated, as GGT is a sensitive marker of alcohol ingestion and certain hepatotoxic drugs.

Normal ValuesNormal ValuesBilirubin <21ALT <40AP female under 60 <104 male and female over 60 <129Albumin 35-50GGT female 7-33 male 11-51

30 year old man30 year old manComplains that after a stag

weekend he felt awful and friends said he looked “yellow”

30 year old man30 year old manBilirubin 28ALT 45GGT42AP 103Albumin 42

48 year old woman48 year old womanSeparated 6/12 agoSays drinks a bottle wine dailyPerhaps more latelyAsking for sicknote due to stressLethargy and retching in morning

48 year old woman48 year old woman

Bilirubin 14ALT 63AP 189GGT 385Albumin 37

61 year old man61 year old man

20 year history alcohol abuse3 x alcohol detox in past 10 yearsComplaining of abdo swellingO/E Distended abdo, no palpable liverMultiple spider naevi

61 year old man61 year old manBilirubin 21ALT 38AP 120GGT 43Albumin 31

What other investigations would be useful?

61 year old man61 year old man

MCV-104

INR 2.3

USS liver- evidence cirrhosis