1. LFT MODULE Department of Medicine Chief Residents

4. Representation of LFTs AST A Φ TB TP ALT DB Alb

5. Normal Values <35 30-120 <1.0 6-8 <35 <0.4 4-6

6. Case #1 A 45 year-old male presents to your Bellevue clinic to establish care. He has not seen a doctor in over 10 years, but has been feeling well. He is unaware of any medical history. His exam is unremarkable. His labs are normal except for the LFTs below: 77 85 0.6 7.8 71 0.2 4.1

11. Case #2 A 20 year-old female was found down in her apartment when she did not show up to her first day of class after winter break. Her apartment has evidence of empty bottles of alcohol. No pill bottles were found. In the ER she was acutely jaundiced, unresponsive, but hemodynamically stable. 1218 191 3.8 7.8 1055 1.6 3.6

16. Case #2 Discussion

17. Case #3 A homeless 63 year-old male with ETOH cirrhosis is brought in by NYPD for disorderly conduct. He endorses diffuse abdominal pain. He is afebrile and tremulous. His WBC count is elevated. His ETOH level is 0. 221 135 4.1 6.2 103 2.2 3.2

23. Transaminitis Summary

25. Case #4 You are medical consult asked to evaluate a G1P0 female at 28 3/7 weeks for A mild pruritic maculopapular rash on the extremities and for the abnormal LFTs below. You learn that these LFTs are new from 1 year ago, but similar to those from her last outpatient appointment 2 weeks ago. 25 213 1.1 8.2 18 0.3 3.8

28. Case #4 Discussion

32. Case #5 A 21 year-old man presents with recurrent episode of sinusitis. He is otherwise healthy; you prescribe amoxicillin. He returns the following week jaundiced and with continued sinus tenderness. 21 115 3.9 7.5 24 0.4 4.1

37. Case #6 A 30 male with schizophrenia on depakote for several months, presented with abdominal pain and yellow eyes for two weeks. He denies changes in stool, nausea, vomiting, fever. Had normal LFTs 3 months ago. 149 281 4.2 7.1 332 3.8 3.9

41. Case #6 Discussion

42. Case #6 Discussion Management of Cholestasis with ductal dilation ? ERCP vs. MRCP Intrahepatic Dilation Extra Hepatic/CBD Dilation Pancreatic Duct Dilation PBC -- -- -- PSC +/- +/-- -- Asian Cholangiopathy + -- -- CBD Stricture + + +/ -- Choledocholithiasis + + +/ -- Pancreatic Mass + + +

43. Case #7 A 28 year-old woman comes in for a refill of her oral contraceptives. She has mild scleral icterus. 28 212 4.1 7.7 22 3.0 4.2

47. Case #8 A 68 year-old female with CAD, HTN, pulm HTN, DM II is admitted from clinic for vague constitutional symptoms and workup of the LFTs found below. She denies recent change in medications. 78 904 1.6 6.6 74 1.0 3.6

51. Cholestasis Review

52. Case #9 A 63 year-old African American Male with diabetes presents to your clinic for the first time complaining of back pain 47 87 0.6 11 51 0.2 4.2

56. Case #9 Discussion Alpha-1 fraction= alpha-1 antitrypsin, thyroid binding globulin. Alpha-2 fraction= ceruloplasm, haptoglobin. Beta-1= tranferrin Beta-2= beta-lipoprotein [IgA, IgM, even IgG at times]. Between Beta and Gamma= CRP, fibrinogen. Gamma= immunoglobulins