Hepatology 101

1. Hepatology 101
August 20, 2015
Douglas Koo, MD, MPH, FACP
Department of Medicine, Hospital Medicine Service

2. Outline
Abnormal LFTs
Biliary tract disease
Ascites

3. LFTs

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. 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. 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. 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. Hepatocellular pattern: AST, ALT in disease
Quinn PG, Johnston DE. Gastroenterologist 1997.

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. 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. Narrowing our differential dx pays off

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. 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. Biliary tract disease

15. Biliary disease

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. 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. 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. 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. Diagnosis

21. Management

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

24. Ascites

29. 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

31. 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.

32. Advancing catheter through skin
Angular insertion Z-tract
or

33. 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)

34. 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.

35. 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

36. SBP treatment: RememberAlbumin

38. Malignant ascites
• Median survival 1-4 months
• Symptomatic relief
– Diuretics
– Tenckhoff catheter

39. Thank you!