Cases & Quizzes LET THE FUN BEGIN !

Some points about LFTs LFTs include the following: Bilirubin ( direct, indirect & total) ALT, AST ( called aminotransferases) Alkaline Phosphatase (AP) Gamma Glutamyl transferase (GGT) P.T./ INR tell us about the Serum albumin synthetic function of the liver

REMEMBER ! If mainly the ALT & AST are high, means damage to the hepatocytes (hepatitis, drug induced liver injury etc) 2) If mainly Alk.Phos & GGT are high, means there is obstruction to the flow of bile outside the liver (eg. CBD stone, CBD stricture, Ca. pancreas etc.) or there is stasis of bile inside the liver ( intra-hepatic cholestasis) eg. Primary biliary cirrhosis, mass lesions in the liver, Primary sclerosing cholangitis,pregnancy

So, in Summary Mainly high AST & ALT: * Hepatitis * Drug injury 2) Mainly high Alk.Phos & GGT: * Post - Hepatic obstruction ( post hepatic cholestasis) * Intrahepatic cholestasis Easy , Right?

Normal ranges of LFTs Total Bili: 0.3 – 1.5 mg% Direct: 0.1 – 0.3 mg% Please Indirect: upto 1.3 Remember ALT: 5-40 iu/L These AST : 12-40 iu/L Alk. Phos : 40-117 U/L GGT: upto 58U/L Slight variations possible in various labs.

Lets Juggle Our Brains ! Bilirubin : 4mg% ( high) Indirect : 3.7 ( high) Direct : 0.3 ( normal) Urine: No bilirubin, but urobilin present No signs of chronic liver disease What picture is this: Prehepatic b) Hepatic c) Posthepatic

Answer 1 PREHEPATIC !

Ques.2 * Total Bilirubin : 8 mg% * Direct: 7mg% ( high) * Indirect : 1 mg% (min high) * AST: 90 ( high) * ALT : 86 (high) * Alk. Phos : 320 ( very high) * GGT: 150u/L ( high) What picture is this ? a) Prehepatic b) Hepatic c) Post hepatic

Answer 2 POST HEPATIC ( VERY HIGH GGT & ALK PHOS)

Ques 3 * Total bilirubin : 6mg% * Direct Bili : 4.5 ( high) * Indirect Bili : 1.5 ( high) * AST : 320 ( v.high) * ALT : 430 ( v. high) * Alk Phos : 110 * GGT : 55 ( little high) What is this picture? a) Prehepatic b) Hepatic c) Hepatic

Answer 3 Hepatic. Most likely hepatitis. ( mainly ALT & AST are high)

Ques. 4 A 20 yr old man is found to have mild jaundice. He gives a similar history off and on but denies any problems from it. Jaundice : Present * No anemia Bilirubin : high * All other LFTs normal Direct bili: normal * Indirect bili: high Urine: no bili but urobilin present What is the most likely diagnosis? What treatment?

Answer 4 Gilbert’s Syndrome. No specific treatment. Reassurance only

Ques 5 A 16 yr old female has jaundice. She has a past history of some “blood disorder” & often gets admitted in the hospital due to body pain. Total Bili: 5mg%(high) * Direct: 0.2 (norm) Indirect bili: 4.8 mg% (high) Other LFTs normal * Hb.: 6mg% Peripheral smear: What type of jaundice is it? What is the diagnosis?

Answer 5 Prehepatic jaundice ( HEMOLYSIS) Sickle cell disease

Ques 6 A 40 yr old female c/o severe colicky pain in the upper abdomen since many weeks. It comes and goes. More after eating.Now, she also c/o yellow discoloration of her eyes & vomiting. Jaundice present * Obese Bilirubin: 6mg% *Direct: 4.5mg%(high) Indirect: 1.5mg% * Alk Phos: 326 ( high) GGT: 100 (high) * Urine bili: present What is the most likely diagnosis? What is the treatment?

Answer 6 * Common bile duct stone * Removal of the stone by ERCP/ surgery

Ques. 7 A 55 yr old female c/o severe itching since few months. She has no DM, HTN etc but is taking treatment for high cholesterol. Jaundice present * No hepatomegaly Scratch marks on the skin Yellow plaques on the eyes Pale stools Total bili: 5mg% * Direct bili: 4.5 AlkPhos: 250( high) * AST: 64( little high) AST : 82( little high) What is the most likely diagnosis? What is the diagnostic blood test? What is the treatment?

Answer 7 Diagnosis: Primary biliary cirrhosis Diagnostic blood test: AMA (antimitochondrial antibody present) Treatment: * urso-deoxy-cholic acid * Liver transplant In PBC, there is intrahepatic cholestasis, due to compression & obstruction of the intra hepatic bile ducts. So bile excretion in the intestine is impaired. Its like an obstructive picture.

Ques 8 A 40 yr old male c/o joint pain & skin discoloration since a few yrs. Jaundice: present * skin: greyish discolor No joint swelling * Blood sugar : high Bilirubin, AST, ALT & Alp Phos: High ( DM + liver disease + skin pigmentation) What is your diagnosis? What tests will you do to confirm What is the treatment?

Answer 8 Diagnosis: Hemochromatosis Diagnostic tests: Serum iron: high Serum Ferritin : High Liver biopsy ( gold standard) Treatment: Repeated phlebotomy( removing blood)

Question 9 A 60 yr old male c/o severe weakness, anorexia and tiredness since few months. He has noticed his abdomen getting big. No H/O any medical problems. History of iv drug abuse in the past & sharing needles. Jaundice: present * Cachexia Abdomen: distended with shifting dullness Nails very white & clubbing Breasts: enlarged LFTs : deranged * Albumin: low

Question 9 (contd) What is your diagnosis? Name 2 “diagnostic” investigations? Name 2 possible causes for this condition in this patient Name some treatments for the causes What complications can occur in this condition?

Answer 9 Diagnosis: Liver cirrhosis Diagnostic tests: * U/S * Liver biopsy Chronic Hep B & C ( H/O iv drug use) Treatments: * Hep B : nucleotide analogues, nucleoside analogues, Interferon * Hep C: Ribavirin, Direct acting antivirals 4) Complications of Cirrhosis: * Ca. Liver * encephalopathy * portal HTN * Ascites * Malnutrition * Hepatorenal syndrome

Some small questions Can Hep A cause cirrhosis? Can LFTs be normal in cirrhosis? Why are there low platelets in cirrhosis? Which drug is used in portal HTN to prevent variceal bleeding? Which antibody in Primary biliary cirrhosis? Name 2 liver diseases caused by alcohol? Which substance is thought to cause hepatic encephalopathy?

Answers to small questions No, Hep A cant cause cirrhosis Yes Cirrhosis portal HTN splenomegaly low platelets 4) Propranolol 5) Antimitochondrial ab. (AMA) 6) Alcoholic hepatitis & cirrhosis 7) Ammonia (NH3)

Questions 8) Name some causes of cirrhosis? 9) Name some complications of cirrhosis? 10) Name 3 things which can be seen in the hand examination of a cirrhosis patient? 11) Name 2 things which can be seen in the chest exam of a cirrhosis patient? 12) Name the findings in the abdomen of a cirrhosis patient? 13) In cirrhosis, is the liver enlarged or small?

Answers 8) Chr. Hep B & C, primary biliary cirrhosis, hemochromatosis, Wilson’s disease, Auotimmune hepatitis, idiopathic, alcohol, drugs 9) Ascites, portal HTN, Encephalopathy, Liver carcinoma, Hepatorenal syndrome, infections 10) Clubbing, palmar erythema, Contractures 11) Gynecomastia, spider nevi 12) Ascites, Bulging umbilicus, caput medusae, splenomegaly, hepatomegaly 13) Can be large or small.

Case 1 A 24 year old male presents with 1 episode of massive hematemesis ( about half a jug of blood). He is not on any medicines for any medical problem. Past hist: i.v. drug use, multiple sexual partners No follow up with any doctor, so does not know if he has any disease or not On exam: Skin & sclera yellow, liver not palpable, abdomen distended

Questions of case 1 What is your diagnosis? Name some treatments used to treat this hematemesis acutely? Name the medicine used to prevent hematemesis in such cases?

Answers of case 1 Esophageal varices rupture causing hematemesis. He most likely has cirrhosis due to Hep B or Hep C. i.v. octreotide, banding, sclerotherapy Propranolol

More questions of cirrhosis 14) Name some causes of portal HTN? 15) Name some complications of portal HTN? 16) Name some things which can precipitate encephalopathy in a cirrhosis patient? 17) Name some treatments used in hepatic encephalopathy? 18) Name 2 blood tests which indicate severity severity of liver disease? 19) Name the scoring system used for prognosis of cirrhosis?

Answers 14) Cirrhosis, portal vein thrombosis 15) Esophageal varices, splenomegaly, ascites, caput medusae ( dilated veins around the umbilicus), 16) GI bleeding, constipation, infection, low blood K, use of sedatives (diazepam), excess proteins in the diet 17) Lactulose (for constipation), iv Proton pump inhobitors ( for GI bleed), Neomycin/ Rifaximin ( to kill GI bacteria)

Answers (contd) 18) Severity of liver disease: P.T./ INR & serum albumin 19) Child-Pughs scoring system

Questions 20) What is the gold standard test for the diagnosis of hemochromatosis? 21) What is the gene causing hemochromatosis? 22) What are the screening tests for hepatocellular carcinoma in a patient with cirrhosis?

Answers 20) Liver biopsy 21) Gene: C 282 Y 22) Ultrasound & serum alpha fetoprotein levels ( once a year or every 6 months)

Small questions of leukemias Which is the commonest leukemia seen in children? 2) Which leukemia shows Auer rods in the cells? 3) Which leukemia shows Philadelphia chromosome in the cells? 4) CLL is a malignacy of which lymphocytes?

Answers of leukemias ALL AML CML B lymphocytes

Question 10 An obese male, who has DM, was found to have slightly elevated liver enzymes. He is asymptomatic. No history of any past medical or surgical history. Denies any alcohol intake. Ultrasound shows slight hepatomegaly & fat deposition in the liver. What is your diagnosis? Which 2 factors in this patient, are causing this liver pathology? Can it progress to cirrhosis?

Answer 10 NASH ( non-alcoholic steato-hepatitis) or Non alcoholic fatty liver disease ( NAFLD) DM, Obesity Yes, in some cases, it can progress to cirrhosis

Case 11 A 23 yr old student c/o cough with sputum since 3 days. Few days before this she had features of flu, myalgias & headache. On exam, she has fever of 38C, no significant findings on chest exam. Skin shows a rash.

Case 11 What is your diagnosis? Name 2 other features, besides the rash, which may be seen in this condition? Which antibiotic would you use?

Answer 11 Mycoplasma pneumonia * Hemolytic anemia * myocarditis * Myringitis ( inflammation of ear drum) Azithromycin or clarithromycin ( macrolides)

Some questions Which bacteria cause typical “Community Acquired pneumonia”? 2) Which bacteria cause atypical pneumonia? 3) Can chest examination be normal in Mycoplasma pneumonia? 4) In COPD patients, which bacteria is commonly the cause of pneumonia? 5) In Legionella pneumonia, which test can you do for diagnosis?

Answers Pneumococci, H.Influenzae Mycoplasma, Chlamydia, Legionella Yes, it can be H.Influenzae Legionella antigen in the urine

Wanna see some X-Rays? PLEASE DON’T SAY NO !

Normal CXR

Normal CXR

Normal CXR

Lobar pneumonia

Lobar Pneumonia

Case 12 A 40 year old male was found to have huge splenomegaly on routine exam. He only c/o some fatigue since a few months. CBC: WBC count 45,000 ( mature looking cells) Low Hb & Low platelets Peripheral smear: Chromosomal analysis shows Philadelphia chromosome

Questions case 12 What is the diagnosis What is the name of the drug which is used?

Answer 12 Diagnosis: CML Drug: Imatinib

Case 13 A 40 year old male c/o tiredness, weakness since 3 wks. Physical exam showed anemia, hepatomegaly and splenomegaly. CBC: WBC count 40,000 Hb. : 9 g/100 ml Platelets : 30,000 Peripheral smear showed large numbers of immature looking WBCs (blast cells).

Ques. case 13 What is your diagnosis? What do you see inside the abnormal cells? Name the drugs used to treat? What are the factors which increase the risk of getting AML?

Answers case 13 AML ( acute myeloid leukemia Auer rods C.D. ( cytarabine, daunorubicin) Things which increase the risk: * Radiation therapy * Chemotherapy for other cancers * Down’s syndrome * MDS ( myelodysplastic syndrome)

Some Quickies Which is the most likely leukemia in each case: Philadelphia chromosome? Auer rods A small child with leukemia An old patient with very high lymphocte count in the blood ( 50,000) Middle aged man with massive splenomegaly A man with a past history of chemotherapy for lung cancer

Answers of Quickies CML AML ALL ( remember atfall) CLL

Last question What are the medicines used to treat CLL?

Last answer Chocolate Cake From Riyadh Chlorambucil, Cyclophosphamide, Fludarabine Rituximab

Thank you Enjoy your evening