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Hepatology 101
August 20, 2015
Douglas Koo, MD, MPH, FACP
Department of Medicine, Hospital Medicine Service
Outline
Abnormal LFTs
Biliary tract disease
Ascites
LFTs
Case
HPI: duration of exposure and LFT abnormalities
PMH: DM, high BMI, autoimmune disease, transfusion
or transplant befo...
LFTs
• Total Protein 8.2
• Albumin 4.6
• TBili 18.9
• AST 1460
• ALT 2645
• Alk Phos 120
• PT 16.4
• INR 1.39
• PTT 35.8
LFTs: the players
LFT Abnormality measured Notes
Albumin Synthetic function Heavy alcohol use, chronic
inflammation, malnu...
LFT pattern is important for DDx
HEPATOCELLULAR
ALT, AST > Alk Phos
CHOLESTATIC
Alk Phos > ALT, AST
*Bilirubin can be elev...
Hepatocellular pattern: AST, ALT in disease
Quinn PG, Johnston DE. Gastroenterologist 1997.
Hepatocellular pattern
Mild (<5x nl) Severe(>15x nl)
Steatosis/steatohepatitis
Chronic hepatitis B, C
Alcohol hepatitis (2...
Back to the case
Acute viral hepatitis (A-E, EBV, CMV)
Medications/toxins
Autoimmune hepatitis
Wilson’s disease
Ischemic h...
Narrowing our differential dx pays off
Cholestatic pattern
Confirm hepatobiliary source (check GGT)
RUQ sono
Dilated bile ducts Non-dilated bile ducts
Extrahepat...
Isolated hyperbilirubinemia
Unconjugated/Indirect Conjugated/Direct
Increased production
- Hemolysis
- Dyserythropoiesis
-...
Biliary tract disease
Biliary disease
Case
• 52F metastatic colon adenocarcinoma
– diagnosed 2y ago, mets to lung, liver, bone, peritoneum
– p/w fever 101 at ho...
Workup
• PE: 37.6 80/54 112 18 95% RA, mild confusion, mild epigastric tenderness
• Labs
• Lactic acid 3.1
• UA +urobilino...
Diagnosis
• Cholangitis; Biliary sepsis
– Ascending bacterial infection from duodenum
– Charcot’s triad (fever, RUQ pain, ...
Management of cholangitis
• Volume resuscitation/restore perfusion, antibiotics for polymicrobial
infection (check out our...
Diagnosis
Management
Chole…
• Cholangitis
• Cholecystitis
– 90% gallstones
– 10% acalculous (critically ill, elderly, post-op)
– ERCP vs cholec...
Ascites
Paracentesis
Indications
• To evaluate new onset ascites of
unclear etiology
• To evaluate for SBP
(spontaneous bacterial
...
Sites
2 cm below umbilicus in midline
- linea alba lacks blood vessels
RLQ or LLQ 2 to 4 cm medial and
cephalad to ASIS
- ...
Advancing catheter through skin
Angular insertion Z-tract
or
Albumin after LVP in portal HTN & cirrhosis
• “interesting” “unresolved” “controversial”
• No study has shown a survival a...
Appearance of ascites
• Clear/translucent yellow: uncomplicated in the setting of
cirrhosis
• Cloudy: infection
• Milky: “...
2 questions: Infection? Portal HTN?
• Cell count: PMN > 250 cells/mm3
• If bloody or >50K RBCs, subtract 1
PMN for every 2...
SBP treatment: RememberAlbumin
Malignant ascites
• Median survival 1-4 months
• Symptomatic relief
– Diuretics
– Tenckhoff catheter
Thank you!
Hepatology 101
Hepatology 101
Hepatology 101
Hepatology 101
Hepatology 101
Hepatology 101
Hepatology 101
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Hepatology 101

Hepatology 101

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Hepatology 101

  1. 1. Hepatology 101 August 20, 2015 Douglas Koo, MD, MPH, FACP Department of Medicine, Hospital Medicine Service
  2. 2. Outline Abnormal LFTs Biliary tract disease Ascites
  3. 3. LFTs
  4. 4. Case HPI: duration of exposure and LFT abnormalities PMH: DM, high BMI, autoimmune disease, transfusion or transplant before 1972 (HBV) or 1992 (HCV) Meds: new meds, vitamins, herbals, OTCs, acetaminophen FH: liver disease, autoimmune disease SH: alcohol consumption, occupational exposure, travel, from viral hepatitis endemic areas, IVDU, tattoos ROS: jaundice, rash, arthralgia, myalgia, anorexia, weight loss, abdominal pain, fever, chills, pruritus PE: Encephalopathy (inverted sleep-wake, irritability, tremor, confusion), asterixis, jaundice, temporal wasting, scleral or sublingual icterus, fetor hepaticus, JVD, spider angiomata, gynecomastia, hepatomegaly, splenomegaly, caput medusae, ascites, testicular atrophy, thenar atrophy, palmar erythema, Dupuytren’s contractures, LE edema
  5. 5. LFTs • Total Protein 8.2 • Albumin 4.6 • TBili 18.9 • AST 1460 • ALT 2645 • Alk Phos 120 • PT 16.4 • INR 1.39 • PTT 35.8
  6. 6. LFTs: the players LFT Abnormality measured Notes Albumin Synthetic function Heavy alcohol use, chronic inflammation, malnutrition PT/INR Synthetic function Low vitamin K, warfarin AST Hepatocellular damage High concentrations in cardiac tissue, skeletal muscle, blood ALT Hepatocellular damage Low concentrations in non- hepatic tissue; more specific Bilirubin Cholestasis, impaired conjugation, biliary obstruction Hemolysis Alkaline phosphatase Cholestasis, infiltrative disease, biliary obstruction Bone disease, leukemia, lymphoma, CKD, CHF, sarcoidosis, hyperthyroidism, hyperparathyroidism, pregnancy, post-prandial
  7. 7. LFT pattern is important for DDx HEPATOCELLULAR ALT, AST > Alk Phos CHOLESTATIC Alk Phos > ALT, AST *Bilirubin can be elevated in both and do not help to distinguish
  8. 8. Hepatocellular pattern: AST, ALT in disease Quinn PG, Johnston DE. Gastroenterologist 1997.
  9. 9. Hepatocellular pattern Mild (<5x nl) Severe(>15x nl) Steatosis/steatohepatitis Chronic hepatitis B, C Alcohol hepatitis (2:1 AST/ALT ratio) Cirrhosis Acute viral hepatitis (A-E, EBV, CMV) Medications/toxins Autoimmune hepatitis Wilson’s disease Hemochromatosis Alpha1 antitrypsin deficiency Celiac disease Nonhepatic: Hemolysis Myopathy (3:1 ratio) Thyroid disease Strenuous exercise Acute viral hepatitis (A-E, EBV, CMV) Medications/toxins Autoimmune hepatitis Wilson’s disease Ischemic hepatitis Acute Budd-Chiari syndrome Acute bile duct obstruction
  10. 10. Back to the case Acute viral hepatitis (A-E, EBV, CMV) Medications/toxins Autoimmune hepatitis Wilson’s disease Ischemic hepatitis Acute Budd-Chiari syndrome Acute bile duct obstruction • Total Protein 8.2 • Albumin 4.6 • TBili 18.9 • AST 1460 • ALT 2645 • Alk Phos 120 Hep A total Ab positive Hep A IgMAb negative Hep B surface Ab positive Hep B surface Ag negative Hep B core Ab negative Hep B PCR <5 IU/mL Hep C antibody negative Hep C PCR <10 IU/mL
  11. 11. Narrowing our differential dx pays off
  12. 12. Cholestatic pattern Confirm hepatobiliary source (check GGT) RUQ sono Dilated bile ducts Non-dilated bile ducts Extrahepatic cholestasis Intrahepatic cholestasis ERCP, MRCP, or CT Check AMA PBC ERCP, MRCP or biopsy Malignant - Hepatobiliary tumor - Porta hepatis node Benign - Choledocholithiasis - Chronic pancreatitis - HIV cholangiopathy - Parasitic infections PBC PSC TPN Sepsis Pregnancy Hepatic congestion/CHF Drugs (steroids, Bactrim) Infiltrative diseases (sarcoid, amyloid, lymphoma,TB, fungal, HCC, mets)
  13. 13. Isolated hyperbilirubinemia Unconjugated/Indirect Conjugated/Direct Increased production - Hemolysis - Dyserythropoiesis -Transfusion - Large hematoma resorption Impaired uptake - CHF - Portosystemic shunt - Meds Impaired conjugation - Gilbert’s syndrome - Crigler-Najjar syndrome - Hyperthyroidism - hepatitis, cirrhosis,Wilson’s *see pathway for Cholestatic pattern
  14. 14. Biliary tract disease
  15. 15. Biliary disease
  16. 16. Case • 52F metastatic colon adenocarcinoma – diagnosed 2y ago, mets to lung, liver, bone, peritoneum – p/w fever 101 at home, chills, rigors, mild abdominal pain • PMH/PSH: biliary stent placed 3wks prior, PE, hypothyroidism, depression, GERD, colectomy, HAIP, cholecystectomy, liver resection, RFA lung mets • MEDS: enoxaparin, synthroid, escitalopram, pantoprazole, celecoxib, fentanyl patch, hydromorphone, laxatives • SH: current 15pk-yr smoker, social EtOH, married • ROS: +epigastric abd pain, +nausea, +vomiting, +rhinorrhea, +nasal congestion, -dyspnea, -chest pain, -cough, -hematuria, -dysuria, +dark urine, - jaundice
  17. 17. Workup • PE: 37.6 80/54 112 18 95% RA, mild confusion, mild epigastric tenderness • Labs • Lactic acid 3.1 • UA +urobilinogen • Blood cultures pending • CXR negative 5 0.4 15 10 32 262 146 3.3 118 24 7 159 5.4 85 307 11.7 33.5 1.1 0.6 3 121
  18. 18. Diagnosis • Cholangitis; Biliary sepsis – Ascending bacterial infection from duodenum – Charcot’s triad (fever, RUQ pain, jaundice) 50-75% – Reynold’s pentad (above + confusion and hypotension) – Up to 40% mortality rate from multiorgan failure (liver, kidney) – Significant endotoxemia – Risk factors: biliary obstruction and stasis (stone, stricture), stent – Imaging: US, CT, MRCP, ERCP, HIDA
  19. 19. Management of cholangitis • Volume resuscitation/restore perfusion, antibiotics for polymicrobial infection (check out our ID website); 80% will respond • DRAINAGE! • Electrolyte management, correct coagulopathy • Consults: ICU, GI, IR (when percutaneous approach needed) • Urgent! Persistent pain, fever, hypotension, confusion
  20. 20. Diagnosis
  21. 21. Management
  22. 22. Chole… • Cholangitis • Cholecystitis – 90% gallstones – 10% acalculous (critically ill, elderly, post-op) – ERCP vs cholecystectomy vs cholecystostomy • Chole(docho)lithiasis – Saturation of bile with cholesterol or bilirubin + stasis – Biliary “colic”: episodic RUQ or epigastric abdominal pain with quick onset and slow resolution min to hours, nausea, fatty foods • Imaging sensitivity: – Cholelithiasis: U/S>CT – Cholecystitis HIDA>CT=U/S
  23. 23. Ascites
  24. 24. Paracentesis Indications • To evaluate new onset ascites of unclear etiology • To evaluate for SBP (spontaneous bacterial peritonitis) in pt with known ascites • To perform large volume paracentesis and provide comfort or relieve respiratory compromise Contraindications • Coagulopathy? • Thrombocytopenia? • DIC • Abdominal wall collateral veins • Abdominal wall cellulitis • Surgical scars • Caution in: – Renal failure, organomegaly, bowel obstruction, intrabdominal adhesions, distended bladder
  25. 25. Sites 2 cm below umbilicus in midline - linea alba lacks blood vessels RLQ or LLQ 2 to 4 cm medial and cephalad to ASIS - lateral to rectus sheath to avoid puncture of inferior epigastric artery An ultrasound study demonstrated that a LLQ tap site is superior to a midline site; the abdominal wall is relatively thinner in the left lower quadrant while the depth of fluid is greater Sakai H et al. Choosing the location for non-image guided abdominal paracentesis. Liver Int. 2005.
  26. 26. Advancing catheter through skin Angular insertion Z-tract or
  27. 27. Albumin after LVP in portal HTN & cirrhosis • “interesting” “unresolved” “controversial” • No study has shown a survival advantage • Reasonable to forego albumin if <5L LVP • I was taught give 50cc of 25% albumin (12.5g) per 2L removed • NEJM article and video: recommend use of albumin if >5 L of ascites removed (6 to 8 g per liter of fluid removed)
  28. 28. Appearance of ascites • Clear/translucent yellow: uncomplicated in the setting of cirrhosis • Cloudy: infection • Milky: “chylous ascites”, high triglyceride concentration, cirrhosis or malignancy • Pink/bloody: traumatic tap, leakage from punctured collateral from previous tap, malignancy • Brown/molasses: if bilirubin is greater than serum, concern for ruptured gallbladder or perforated duodenal ulcer Diagnosis and evaluation of patients with ascites. UpToDate.
  29. 29. 2 questions: Infection? Portal HTN? • Cell count: PMN > 250 cells/mm3 • If bloody or >50K RBCs, subtract 1 PMN for every 250 red cells • Culture used to confirm diagnosis of SBP – Volume affects culture sensitivity; goal 10cc per bottle – Fill culture bottles at bedside • SAAG = Ascites albumin value – Serum albumin value
  30. 30. SBP treatment: RememberAlbumin
  31. 31. Malignant ascites • Median survival 1-4 months • Symptomatic relief – Diuretics – Tenckhoff catheter
  32. 32. Thank you!

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