okay so welcome to another MedCram
lecture we're talking about liver
function tests it's the third lecture
where we talk about actual diseases and
I wanted to break them up into acute
liver diseases chronic and finally
cholestatic so let's get started okay so
here I've made a table of some of the
characteristics of hepatitis in the
acute form let's talk about hepatitis A
remember that hepatitis A is is an oral
transmission so you don't get it by
blood you get it by the soil not washing
their hands and then getting into the
food and then there's sort of a fecal
oral transmission you get it but because
this is the liver you're going to see an
increased amount of alt over ast both go
up but you're going to see more of an
alt type of bound up over the ast and so
how are you going to diagnose this
remember it's the eye G m and T
hepatitis A virus okay so that's how you
make the diagnosis now with hepatitis B
on the other hand it's not oral but it's
intravenous intravenous or body fluid
okay and in this situation it's very
similar to hepatitis A and that the alt
is going to be higher than the ast
because this is the liver that's being
attacked and not muscle or something
else with hepatitis B remember there's
different antigens there's surface
antigens and there's cor antigens and
that's important because if you get an
immunization you're going to have
antibodies against the surface antigen
so if I could draw a little example here
if this is the virus particle the blue
is the surface and the core
is the green the core is the actual
viral particle so when they give a
vaccine they're just using the blue
portion of the virus the non-infectious
so you're going to have antibodies that
are going to be made against the surface
antigen so you so if you have an
immunization you should be surface
antibody positive but you should be core
antibody negative because they never
gave you the core and so what this means
is that you should the IgM antibody to
the hepatitis B core antigen should be
positive if you actually have the
infection let me restate that here so
the i GM core antibody is positive again
the IgM antibody to the hepatitis B core
antigen is positive that's called the
IGM anti-hbc c stands for the core and
you should also have it positive to the
surface antigen so both of those should
be positive okay because in an actual
infection you're getting the surface and
you're also getting the core so you
should have IgM
you should have both of those so again
the IgM antibodies of the hepatitis B
core antigen and to the hepatitis B
surface antigen both should be positive
okay what about hepatitis C again
hepatitis C is actually a little bit
more chronic and so you're not going to
see as much of an increase here but
again the key point here is the ast is
going to be less and increased than the
alt again this is intravenous drug use
or IV DEA abuse okay
there's other things that are associated
with this like tattoos also sharing
razors multiple sex partners these sorts
of things can increase the risk of
spreading hepatitis C now how do you
check for that it's very simple it's
simply the anti HCV antibody into IgM
you could also check for the hepatitis C
virus RNA within the first three months
of the exposure you should have an
antibody reaction though okay alright
let's talk about alcohol now whereas
before the alt was higher than the ASD
because this is the liver be aware that
in alcohol they're about the same or you
might even see that the ast is going to
be higher than the alt is that
interesting and obviously here instead
of intravenous drug use we're going to
get alcohol use so that's that's
obviously very important difference
there obviously you want to make sure
that there's not other things going on
here so the diagnosis is basically based
based on history
what about ischemic now remember an
ischemic you're getting no blood flow to
the liver so the liver is going to be
really upset with that and it's going to
tell you that and so what you're going
to see is humongous raises
the ast and the alt and we're talking
several thousand here okay so they
really go up in ischemic disease and
obviously you're going to have blood
pressures here in the 50s / 30s or
something really bad like that or a code
situation and again you're going to be
ruling out other things here but if you
see this go up and shoot up pretty
quickly I want you to think of ischemia
and you just again is going to be based
on the history okay let's talk about the
chronic diseases now obviously you can
get chronic hepatitis B and C and you
don't get chronic hepatitis A or it's
very rare so I left those off of here
basically they look identical as to the
acute situation except the liver enzymes
are not as elevated let's talk about
mash probably one of the most common it
stands for non-alcoholic steatohepatitis
basically these patients are fat obese
so you're talking about patients with
for instance the metabolic syndrome
insulin resistance hypertriglyceridemia
and in the history you're going to
basically get for the diagnosis is that
of exclusion you certainly don't want to
just look at someone say they're fat and
that's why you've got nash but these
type of patients what do they look like
these patients are liver patients so
they're going to have a slightly
increased alt over that of the AST but
the alt will be higher than the ASD but
it'll be it'll be elevated now as we
said with alcohol it's very it's just
backwards the alt is high but the ast is
what's elevated and again the history is
going to be that of EtOH and a guess
it's also going to be of exclusion you
want to just make sure that you're not
just subscribing somebody to the old
alcohol reason for their liver disease
make sure that even though they're
drinking make sure you rule out the
other things autoimmune hepatitis that's
that's the reason why we need to rule
this out if you have a middle-aged woman
who drinks a lot you certainly don't
want to say that it's due to just for
drinking because it could be due to
autoimmune disease these are the type of
patients that get autoimmune disease
these young women so because it's an
autoimmune hepatitis
itis again it's in the liver they're
going to have a higher alt than AST so
the history in this is that they're
young women that's the type of people
who get these autoimmune diseases and
the thing here that you got to know is
this this is for boards and it's the
anti smooth muscle antibody if that's
positive it's going to be very difficult
to say that this is all related to
alcohol disease so look for positive
Auto antibodies and to nuclear
antibodies but specifically the answer
they're looking for is anti smooth
muscle antibodies ok humic row mitosis
this is uncommon in women it's usually
because why they have periods and they
lose iron so they it's very hard to
store up with iron but the history here
is that it's typically in men and what
are we going to see here well if you
take the ferritin level and the iron
saturation that's the where you take the
iron the serum iron and divided by the T
IBC you're going to get something
greater than 55 percent and usually
you're ferritin level is greater than a
thousand so you're off the charts with
this and of course the history is that
of something called bronze diabetes and
this shows up on test a lot and the
reason does is because it's got a very
specific presentation basically iron
infiltrates a lot of the endocrine
organs of the body the iron infiltrates
the pituitary okay so they can get
pituitary problems it infiltrates the
pancreas so what do they get they get
diabetes it infiltrates the heart so
they get what and CHF or some sort of
constrictive cardiomyopathy okay so look
for this patient with diabetes who has a
bronze look to themselves
now there's an iron metabolism
deficiency that you should know it is on
chromosome six and how do you remember
that I remember that
comes in a 2 plus form and also in a 3
plus form the Pharos and the ferric form
and I know that 2 times 3 is equal to 6
so that's how I remember it's on
chromosome 6 I don't think they will
ever ask you that but you can certainly
impress your friends with that bit of
knowledge ok what about Wilson's disease
I think Wilson's disease showed up on a
famous television show once and those of
us who studied knew what the diagnosis
was before the end of the show you're
going to have increased alt and ast the
history here with Wilson's disease is
that they're young they get this kind of
korea form movement disorder and
psychiatric disease but the key here is
this thing's called the kaiser ka y ser
Fleischer f.l.e.i.j.a h ER rings so
Google that or look that up on the
internet and see what Kaiser Fleischer
rings are in the eyes and you will see
that and the key here is not a high but
a low zero plasmon and why is that
because it's trying to suck up all the
copper this is a abnormal copper
deposition so you get hemolysis and
actually you get a low alch foss and a
low serum and plasma ratio okay and now
the one that's most near and dear to my
heart is alpha 1-antitrypsin you
specifically we see this with patients
with lung disease
remember antitrypsin alpha 1-antitrypsin
is an enzyme that is in your lungs it's
made in your liver as well and what it
does is it protects these elastase --is
from breaking your elastin fibers and so
if you don't make alpha 1-antitrypsin
you have something called alpha
1-antitrypsin deficiency and you tend to
get emphysema more quickly well that's
not the only thing that can happen
you can get a buildup of this abnormal
protein in the law in the liver and
you'll see these past positive pass
positive granules in the liver and you
will get liver disease it's a very kind
of a low-level liver disease so you're
not going to see it going very high but
on the history you're going to have COPD
asthma certainly if they smoke very
early in life if they don't smoke
they'll have COPD later in life and
they'll scratch your head say well how
did I get the COPD I've never smoked
well get an alpha 1-antitrypsin level
the thing that you should know there is
the worst form of it is the p i-- z z
allele okay and the normal is the mm but
the z z is the worst
and that's homozygote recessive okay so
this is autosomal recessive autosomal
recessive inheritance and so you check
how do you make the diagnosis you don't
obviously do a liver biopsy first off
but you simply get an alpha
1-antitrypsin level and then have them
see a liver doc okay so let's talk about
next the characteristics of cholestatic
liver disease and for that join me for
the next lecture number four
you
you
