Deranged LFTs Pathways

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Deranged LFTs Pathways. A H Mohsen. Dr A H Mohsen MD (KCL), MRCP, DTM&H Consultant Gastroenterologist. Main causes for progression of liver disease. Alcohol consumption Obesity Hepatitis B/C. Common serum liver chemistry tests. How common abnormal LFTs?. - PowerPoint PPT Presentation

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  • Deranged LFTsPathwaysA H MohsenDr A H MohsenMD (KCL), MRCP, DTM&HConsultant Gastroenterologist

  • Main causes for progression of liver disease

    Alcohol consumptionObesityHepatitis B/C

  • Common serum liver chemistry tests

    AST/ALTHepatocellular damageBilirubinCholestasis, impaired conjugation, or biliary obstructionGGTCholestasis or biliary obstruction

    Alk-PCholestasis, infiltrative disease, or biliary obstruction PT/AlbuminSynthetic function

  • How common abnormal LFTs?Abnormal LFTs: 1%4% of the asymptomatic population

    Those who have LFTs check: >10 are above twice limit of normalabnormal test result resolve spontaneously in 38% of patientsGastroenterology 2002Ryder, BMJ 2001

  • 149 asymptomatic patients with elevated alanine aminotransferase levels who underwent liver biopsyScand J Gastroenterol 1986

    Cause%Fatty live56Non-A, Non-B hepatitis22Alcohol related11Hepatitis B3Other diagnosis8No cause2

  • 1124 consecutive patients with chronic elevations in aminotransferase levelsAm J Gastroenterol 199981 no definable cause had LB

    CauseNumber Steatosis41NASH26Fibrosis4Hepatitis B3Cirrhosis2Normal8

  • Abnormal LFTsRaised ALK-PALT/ASTIsolated rise Bili up to 3x ULNexclude haemolysis andConjugated bilirubinProbably Gilberts

  • Abnormal LFTsRaised ALK-PALT/ASTIsolated rise Bili up to 3x ULNCheck GGTRaised: x2 ULN>3 monthsNormal:Bone diseaseUSS & AMAabnormal:referNormal: repeat in 3-6 monthsTrend not improving

  • ALT/ASTALT>400100-400 mod RiskALT3 monthsHep A,E,CMV,EBVUSS, liver screenUSS & liver screenReferral to GastReview 1-3 /12No further actionNormal

  • USS & liver screenPositive screenNegative screenTreat diagnosisReferral to GastFat on USSNAFLD + ETOHNo fat on USS

  • Fatty liver (NAFLD/NASH)Fibro-scanReferral to Gast> 7If > 3 criteriaLife style interventionRepeat fibro-scan in 1-2 yearsGP to monitor< 7

    CriteriaLow riskHigh riskAge 45Diabetes/IFGAbsent PresentBMI30AST/ALT1Platelet count>15034

  • Isolated elevation of GGTLevels > 3 times upper limit of normal:Repeat in 3 monthsAlcohol intake adviceReview medicationsIf trends worseningUSS & fibro-scanLevels < 3 times upper limit of normal:Monitor 6-12 monthlyAlcohol intake adviceReview medicationsRefer to Gastfibro-scan > 7fibro-scan > 7

  • Recent case ST, 62 malePresented in March with severe UGIBStabilisedOGD: Likely gastric varices (D/W Addenbrokes)Catastrophic variceal bleed 10 hours later DiedPMH:Type II DM (1999)HypertensionIHD

  • ST, 62 maleCurrent medications:1. NovoRapid 20-40 units pre meal2. Lantus 40 units pre bed3. Metformin MR 1g bd4. Bendroflumethiazide 2.5mg5. Omeprazole 5mg6. Diltiazem MR 90mg7. Irbesartan 75mg

  • Ref. Range12/03/2014 22/09/2011 02/11/2010 27/10/200831/01/2007 ALP(30-130)105359328297228Albumin(35-50)3138404641ALT(0-41)3774889378Total Bilirubin(0-20)2218211314

  • NAFLD prevalenceLiver biopsy/post-mortem series 15-39%Third of the population was found to have hepatic steatosis in US (MRI)

    Obese personsNAFL 60-90%, NASH 20-25%, cirrhosis 2-3%Diabetic : 50 %Morbidly obese and diabetic personNAFL 100%, NASH 50%, cirrhosis 19%Dixon J 2001, silverman J 1989, 1990Hultcrantz R 1986, Ground K 1982Hepatology 2004; 40:1387

  • Examination ProcessA mechanical pulse is generated at the skin surface, which is propagated through the liver. The velocity of the wave is measured by ultrasound.The velocity is directly correlated to the stiffness of the liver, which in turn reflects the degree of fibrosis. - the stiffer the liver is the greater the degree of fibrosis.

  • Project OverviewA novel diagnostic pathway to detect significant liver disease in the community

    Amount Won 100,000

    Innovation Challenge Prize Winner, November 2013

  • Summary Clear pathwaysNAFLD is the most common cause 1/3 of deranged LFTs resolve spontaneouslyIdentify those at risk and refer early

    Liver disease is the fifth biggest killer in the UK and the only out of five still seeing an increase******The rapid increase in obesity prevalence is not only limited to the developed world but is rapidly occuring in the countries under transition, and most of the middle income countries. Even in the poor countries, the rapid urbanisation is contributing to localised rise in the prevalence