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Continuing Medical Education Questions: January 2017: ACG Clinical Guideline: Evaluation of Abnormal Liver Chemistrie

Umashanker, Renuka MD, FACG1

American Journal of Gastroenterology: January 2017 - Volume 112 - Issue 1 - p 36
doi: 10.1038/ajg.2016.571
PRACTICE GUIDELINES
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1Gastroenterology Center of Connecticut, Hamden, CT

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Questions:

  1. The standard comprehensive metabolic profile panel includes aspartate aminotransferase (AST), alanine aminotransferase (ALT), alkaline phosphatase, bilirubin, and albumin.What should the clinician understand when evaluating a patient with abnormal liver function tests?
    1. Liver chemistries including ALT, AST, alkaline phosphatase, and bilirubin are markers of liver injury.
    2. The laboratory measurements of ALT, AST, and alkaline phosphatase are not usually reproducible.
    3. Liver chemistries including ALT, AST, alkaline phosphatase, and bilirubin are markers of liver function.
    4. Mild elevations of AST and/or ALT, alkaline phosphatase, and bilirubin do not require further evaluation.
  2. Which one of the following statements is true of liver chemistry tests?
    1. A relationship between ALT level and body mass index (BMI) has not been clearly identified.
    2. Elevated ALT or AST in a patient without identifiable risk factors is not associated with increased liver-related mortality.
    3. Normal ALT in patients without identifiable risk factors for liver disease is 29-33 IU/L for males and 19-25 IU/L for females, and levels above this should be assessed.
    4. Normal ALT excludes the presence of significant liver disease.
  3. A 43-year-old woman with a history of diabetes, hypertension, and dyslipidemia was referred to you for further evaluation of abnormal liver chemistries. She was in usual health until 6 weeks ago, at which time she developed an upper respiratory infection. Initially it was thought to be viral but she did not improve despite azithromycin 500mg for one day then 250mg daily for 4 days. Her symptoms did not improve, so she was given a course of cefuroxime 250mg BID for 10 days. Her upper respiratory symptoms improved but she had worsening fatigue and malaise. She was jaundiced at a follow-up visit with her primary care physician. Complete blood count and electrolytes were normal upon evaluation, though liver function tests showed alkaline phosphtase 330IU/L, AST 130IU/L, ALT 190IU/L, and bilirubin 2.9mg/dL. Abdominal ultrasound showed fatty liver but was otherwise normal with no ductal dilation and a normal gallbladder. She does not use any other over-the-counter medicines and drinks alcohol rarely. Physical exam is notable for icteric sclera but is otherwise normal. Based on R-ratio calculations, what is the pattern of this patient's liver injury?
    1. Hepatocellular
    2. Cholestatic
    3. Mixed pattern
    4. None of the above
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