St. Charles Advanced Illness Management 2019-10-10¢  ¢â‚¬¢...

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Transcript of St. Charles Advanced Illness Management 2019-10-10¢  ¢â‚¬¢...

  • Terrance M. James, NP-C St. Charles Advanced Illness Management

    Elevated Liver Function Tests: A Case Based Approach

  • • Identify patterns of abnormal liver function tests

    • Identify appropriate choices of liver related laboratory tests

    • Identify appropriate choices for liver imaging studies

    • Identify the elements that make the diagnosis of particular liver diseases

    Objectives

  • • Have they been confirmed more than once over a 1-2 month window?

    When are liver chemistries considered abnormal?

  • • Is the pattern consistent, changing, or evolving?

    When are liver chemistries considered abnormal?

  • • What has changed in their history? Medications? Substances? Supplements?

    When are liver chemistries considered abnormal?

  • ALT >30 IU/L males or, ALT >19 IU/L females or,

    ALP >120 IU/L

    Repeat & confirm in 1-2 mo

    If resolved, repeat in 3-12mo

    if alcohol, illicit drug use, medications or supplements (inc. herbal) suspected:

    adjust and repeat in 3mo

    Total bili >5 and, abnl ALT +/- abnl ALP

    Urgent u/s HbsAg, HBcAb IGM

    HAV Ab IGM

    Consider GI referral

    Isolated total bilirubin

    Fractionate bilirubin

    >15% direct

    Dubin-Johnson or Rotors syndrome

  • 1. Cholestatic

    2. Hepatic

    Patterns of abnormal liver function tests

  • • Alkaline phosphatase higher than AST/ALT levels • Alkaline phosphatase higher with near normal

    AST/ALT levels – sometimes referred to as infiltrative pattern

    • Bone, first trimester placenta, kidneys and intestines can also lead to elevations in Alkaline phosphatase

    • Adding on a GGT can help determine if this is a liver process in the setting of Alkaline phosphatase > AST/ALT

    1. Cholestatic

  • • Alkaline phosphatase higher than AST/ALT levels

    Cholestatic

  • • Alkaline phosphatase higher than AST/ALT levels • Alkaline phosphatase higher with near normal

    AST/ALT levels – sometimes referred to as infiltrative pattern

    Cholestatic

  • • Alkaline phosphatase higher than AST/ALT levels • Alkaline phosphatase higher with near normal

    AST/ALT levels – sometimes referred to as infiltrative pattern

    • Bone, first trimester placenta, kidneys and intestines can also lead to elevations in Alkaline phosphatase

    Cholestatic

  • • Alkaline phosphatase higher than AST/ALT levels • Alkaline phosphatase higher with near normal

    AST/ALT levels – sometimes referred to as infiltrative pattern

    • Bone, first trimester placenta, kidneys and intestines can also lead to elevations in Alkaline phosphatase

    • Adding on a GGT can help determine if this is a liver process in the setting of Alkaline phosphatase > AST/ALT

    1. Cholestatic

  • AST and or ALT Alkaline phosphatase

    Hepatic/Hepatocellular

    Higher Than

  • Skeletal muscle Cardiac muscles Red blood cells Kidneys

    Hepatic/Hepatocellular

    Elevations in AST/ALT Can All Lead To

  • When AST is 2x greater than ALT: Add a GGT to help determine if it’s an alcoholic injury

    Hepatic/Hepatocellular

  • • Platelets – helpful to determine the extent and length of disease, low platelets think low function

    • Bilirubin – high bilirubin reflects poor liver function and high amount of liver injury

    • Albumin – low albumin reflects changes in their nutritional status that could be related to their liver disease

    • INR – high INR think liver damage and poor function

    Other Labs

  • • 60 year old white male, originally from the New York area, resettled in Portland 20+ years ago

    • Persistently elevated LFTs for several years

    • Felt to be due to fatty infiltration seen on Ultrasound by PCP as patient has diabetes, high cholesterol and high blood pressure; he also has RLS, colon polyps, HSV2, GERD, ED, and Achilles Tendonitis

    • He is a gay male, happily married to same partner for 20 + years

    • Reports distant IV and intranasal drug use “It was the 70’s”

    • Family history of metabolic disease, alcoholic liver disease and “I think someone had cirrhosis”

    • Has reports of frequent fatigue, “since I got diagnosed with Diabetes,” about 15 years ago

    Our First Case….Meet Hal

  • Mrs. Nguyen • 35 yo Vietnamese Female, newly pregnant at 13 weeks, routine screening shows

    her Hep B positive – Surface Ag positive • E antigen positive, DNA 70 million, AST 22, ALT 18, ALK Phos 40, Bili 0.8 • Mother and 2 brothers with Hep B • Daughter has been vaccinated, Spouse unknown vaccine or disease status • Follow-up at 28 weeks shows DNA of 54 million

  • Wesley • 38 year old married accountant • Has noted sudden onset of jaundice, icterus,

    abdominal swelling and lower extremity swelling about 1 week prior to presentation; wife wanted him to come in early for this but he refused

    • Felt weak last night and presented to PCP • Noted to be hypotensive 88/58, Pulse 122 • Not making urine, can barely get from chair to the

    bed • Massive ascites on exam, 3+ pitting edema, he has

    telangiectasias and spider angiomata

  • William • 29 yo mixed race male (white and Chinese) • BMI of 53 • Has hyperlipidemia and hypertension • Drinks 2-3 beers most nights, more on the weekends • Lab at PCPs office: alkaline phosphatase 128, , AST

    70, AST 56, T Bili 1.1, A1c 5.8, Triglycerides 400, GFR >60

    • Liver US shows increased echogenicity • Quit drinking for 2 months • Follow-up labs: ALT 59, ALT 50T Bili 1.0, Ferritin 865

    – referred to GI

  • Tina • 24 year old mixed race female • Used heroin and meth from age 16 to 23 • Clean and sober for 5 months • Tested positive for Hep C ab in rehab • Presents to clinic with her mother for discussion of

    treatment • Recent flu like illness and massive fatigue that are

    now gone • No recent LFTs, never had a HCV Quant PCR

  • Ernest • 55 yo African American male • Uses heroin intranasal now but prior IV use • Hep C for at least 29 years • Hx of Hep B and jaundice but told that he cleared it • Prior Interferon/Ribavirin non-responder • Told at that time he was cirrhotic • Has not seen primary care in 10 years, recently re-established

    and now wants “Harvoni,” like on TV per referral • Has RUQ pain, changes in appetite and weight loss

  • • 29 yo mixed race male (Caucasian and Chinese) • BMI of 53 • Has hyperlipidemia and hypertension • Drinks 2-3 beers most nights, more on the weekends • Lab at PCPs office: alkaline phosphatase 128, , AST

    70, AST 56, T Bili 1.1, A1c 5.8, Triglycerides 400, GFR >60

    • Liver US shows increased echogenicity • Quit drinking for 2 months • Follow-up labs: ALT 59, ALT 50T Bili 1.0, Ferritin 865

    – referred to GI

    Chet

  • • Substance History – we know he used IV and intranasal drugs so did you get hepatitis?

    • Viral Hepatitis – CDC recommendations currently anyone born between 1945 and 1965 ie. > 50 needs Hep C checked

    • Autoimmune History – patient and family – if patient or family member has an AI disease, chances are higher for other autoimmune disease

    • Bleeding – signs of low platelets and high INRs

    What questions should we ask?

  • • 60 year old white male, originally from the New York area, resettled in Portland 20+ years ago

    • Persistently elevated LFTs for several years

    • Felt to be due to fatty infiltration seen on Ultrasound by PCP as patient has diabetes, high cholesterol and high blood pressure; he also has RLS, colon polyps, HSV2, GERD, ED, and Achilles Tendonitis

    • He is a gay male, happily married to same partner for 20 + years

    • Reports distant IV and intranasal drug use “It was the 70’s”

    • Family history of metabolic disease, alcoholic liver disease and “I think someone had cirrhosis”

    • Has reports of frequent fatigue, “since I got diagnosed with Diabetes,” about 15 years ago

    Our First Case….Meet Hal

  • • Meformin XL 500 mg, Atorvastatin 10 mg, Lisinopril 10 mg, Requip 0.25 mg, Cialis 20 mg, and ASA 81 mg

    • BP 118/74, P 81, BMI 26 • Alkaline Phosphatase 54 • ALT 87 (79 one year ago) • AST 52 (48 one year ago) • Bilirubin total 1.1 • Albumin 3.8 • Total Protein 6.6 • A1c 6.3 • LDL 88, Triglycerides 125

    Our Case….Meet Hal

  • • Had Hep B he thinks in 1973, and in 1978 had Hep A, no subsequent checks or testing

    • He and his partner love Italy/Italian food and wine; drink at least one glass of wine a night

    • Thinks he has had high liver function tests for a long time

    • Smokes some pot and eats edibles to help with sleep and RLS

    • No autoimmune disease but thinks a cousin had an issue with iron

    • Never had any acute bleeding events

    Now that you mention it….

  • • Hep B surface antigen negative, core IgM negative (