Edics clinical pathways: lower urinary tract symptoms

MEDLInC CLINICAL PATHWAYS: ABNORMAL LIVER FUNCTION TESTS
What is normal varies by ethnic origin and age. The term "normal range" introduces further confusion, as the values reflect a statistical range and not a definition of what is not pathological. Results outside of these ranges, therefore, do not necessarily indicate disease. The first step is to evaluate the clinical context in which abnormal tests are found. In particular, whether the observed biochemical abnormality is associated with a history suggestive of liver disease and/or symptoms and signs of liver disease, or with the presence of extrahepatic conditions that may
involve the liver.
TRANSAMINASES:
Abnormal transaminases in asymptomatic patients without risk factors for, or clinical
features of, liver disease:
If raised and <3x upper limit of normal - recheck in 1-3 months
If still raised (two measurements, six months apart) - further investigation indicated.
If more than three times upper limit of normal (single measurement), further investigation indicated as
shown in the table
Abnormal transaminases in patients with risk factors for, or clinical features of, liver
disease?
Further investigations are advised for any enzyme rise associated with risk factors for, or clinical
evidence of, liver disease except where an apparent cause is found (hypertriglyceridaemia, diabetes,
alcohol, overweight), for which a six month trial of appropriate intervention is recommended.
Investigations in asymptomatic patients with raised liver enzymes
Test
Abnormality
Interpretation
Suggested first investigation
Full blood count
Suggests alcohol excess if gamma glutamyl transferase also raised. Possible hypersplenism Strongly suggestive of autoimmune hepatitis Possible haemochromatosis, modest levels common in alcoholic fatty liver disease, alcoholic hepatitis, and non-alcoholic fatty liver disease - seek advice if raised Chronic infection proved. Referral required Chronic infection possible. Confirm viraemia with If no diagnosis obtained
Liver ultrasound
T-transglutamase antibodies Alpha 1 antitrypsin Suggests deficiency; phenotype required (possible urine copper) as dictated by
clinical context

GAMMA GLUTAMYL TRANSFERASE
Elevation typically indicates cholestasis or, when alkaline phosphatase is normal, induction of hepatic
metabolic enzymes, often in response to long term exposure to excessive alcohol or drugs.
MEDLInC CLINICAL PATHWAYS: ABNORMAL LIVER FUNCTION TESTS


MEDICATION AND ABNORMAL LIVER FUNCTION TESTS
Antibiotics: Penicillin, Ciprofloxacin, Nitrofurantoin, Fluconazole, Isoniazid, Rifampicin
Antiepileptic: Phenytoin, carbamazepine Statins, NSAID, ACE inhibitors Herbal remedies Drugs and substances of abuse: Cocaine, ecstasy, glues and solvents
RAISED BILIRUBIN IN AN ASYMPTOMATIC ADULT:
Values up to 20% more than the upper limit of normal are likely to be statistically rather than clinically "abnormal" Values <1.5 times the upper limit of normal - retest in 1-3 months unless clinical suspicion of disease Values >1.5 the upper limit of normal - confirm proportion of indirect (unconjugated) bilirubin. If >70% of bilirubin is unconjugated, the diagnosis is probably Gilbert's syndrome: no further testing is needed if the bilirubin is not rising on interval retesting, unless haemolysis is suspected. If unconjugated bilirubin is rising on retesting, consider haemolysis and test haptoglobin, lactate dehydrogenase, and full blood count with reticulocyte count Values >3 times the upper limit of normal - clinical disease is likely and further investigation is required. Consider: Ultrasound (if >50% of bilirubin is conjugated) or Tests for haemolysis (if >70% is unconjugated).
RAISED ALKALINE PHOSPHATAE IN AN ASYMPTOMATIC ADULT:
Think of causes outside the liver such as fracture , Paget's disease, osteomalacia, pregnancy and
growing children.
TWO COMMON CLINICAL CONDITIONS:
Alcoholic liver disease:
This is one of the most common reasons for mildly abnormal aminotransferase levels in the Western world. The quantity and duration of alcohol use are important for establishing a diagnosis. A clue to the diagnosis is that the AST/ALT ratio in these patients is typically 2:1 or more. When a patient's history is not reliable, increased GGT levels with normal ALP levels and macrocytosis make alcohol induced liver damage more likely.
Fatty infiltration of the liver or non-alcoholic steatohepatosis (NASH).
Fatty infiltration of the liver, with or without associated inflammation and fibrosis, is thought to be the
most common cause of mild abnormality of aminotransferase levels in the general population in Western countries. Nevertheless, the exact prevalence of non-alcoholic fatty liver disease is quite difficult to ascertain because the disease is asymptomatic and there are no blood tests to confirm the diagnosis. Furthermore, although risk factors for non-alcoholic fatty liver disease, such as obesity, diabetes mellitus, and hyperlipidaemia, are present in a variable proportion of affected patients they are not specific. Therefore the initial evaluation of a patient with abnormal liver function tests and suspected non-alcoholic fatty liver disease should include a complete serological evaluation to exclude other causes of liver disease Just because liver function tests are normal, you should not assume that the patient doesn't have liver disease. For example about one third of patients with hepatitis C have normal ALT levels despite inflammation on liver biopsy.

Source: http://medlinc.co.uk/PDFs/Liver_Function_Tests%5B1%5D.pdf