Liver and Biliary Tract Disorders

5 Liver and Biliary Tract Disorders



Abnormal liver biochemistry


‘Liver function tests’ are routinely requested.


Serum bilirubin, aminotransferases, alkaline phosphatase, γ-glutamyl, transpeptidase (γ-GT) and total proteins are measured. These are in fact tests of liver damage (hence the term ‘liver biochemistry’) rather than actual liver function. Liver function is assessed by serum albumin and the prothrombin time.






The doctor asks: would an ultrasound be helpful?


No. This is not the pattern of biliary or pancreatic disease.


You arrange to see the patient with your consultant in outpatients. At outpatients the history again is unhelpful. There is no history of:



On examination you notice a few spider naevi. The liver is not palpable.


The results of the tests performed by the doctor are now available (Table 5.1). HCV antibodies indicate HCV infection (chronic hepatitis) and the patient will require HCV RNA, liver biopsy and possible treatment with anti-viral therapy with pegylated interferon and ribavirin, or with one of the newer protease inhibitors (boceprevir or telaprevir).


Table 5.1 Further investigations into the cause of the abnormal liver function test































Test Result Implication
Repeat LFTs Similar to above  
Hepatitis A IgG positive
IgM negative
Patient has been infected with HAV in the past or immunised. This virus does not cause chronic liver disease
HBsAg Negative See below
HCV antibodies Positive  
Autoantibody screen Negative Positive titres usually found in autoimmune hepatitis
Serum ferritin 110 µg/L This excludes hereditary haemochromatosis

Armed with the HCV result you discuss IV drug use with your patient, who then admits to the very occasional use of IV drugs in the 1960s.


Although this patient did not have HBV, you need to know the significance of HBV markers (Table 5.2).





Jaundice


Jaundice is detected clinically when the serum bilirubin is greater than 50 µmol/L (3 mg/dL).




Ultrasound in extra-hepatic obstruction can show:



In this patient, the ultrasound showed gallstones in the gall bladder and a dilated common bile duct. Provided this patient’s clotting is satisfactory, the next procedure should be an ERCP. This would enable a better visualisation of the system and would allow a gallstone that is causing the obstruction in the common bile duct to be removed. A sphincterotomy would need to be performed beforehand and the stone could be removed with a basket or a balloon. If the stone is very large, the stone can be crushed and the debris removed. In an elderly patient, stent insertion to maintain drainage is an option.







Further investigation


Viral markers for the above causes, and paracetamol levels, must be obtained urgently. Other investigations would include the following if no cause has been found:



In this case, the patient’s relatives arrive and say they have found empty containers labelled paracetamol 500 mg tablets in her bedroom at her apartment.


The patient might well stabilise at this stage but a close eye will need to be kept on her for potential infections, particularly with opportunistic organisms. It is reasonable to give Acetylcysteine in the initial management of such comatosed patients, whether or not the paracetamol blood level is high.


This patient’s clinical condition deteriorated, with a modified early warning score (MEWS) score of 5. She became increasingly drowsy and confused and developed a flapping tremor and fetor hepaticus. Her investigations now showed a serum bilirubin of 320 µmol/L, ALT 4200 U/L, AST 3800 U/L, serum albumin 32 g/L, with an INR of 3.62. Urgent advice was sought from the nearest liver unit.



You arrange for transfer. In specialised units 70% of patients with paracetamol overdose and grade IV encephalopathy survive. Factors that indicate a poor prognosis with paracetamol overdose (without transplantation) are:


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Apr 3, 2017 | Posted by in GENERAL & FAMILY MEDICINE | Comments Off on Liver and Biliary Tract Disorders

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