Mirrors ALP so can be used to confirm if a rise in ALP is of hepatic origin
Raised with alcohol abuse and enzyme-inducing drugs
Extravascular haemolysis results in breakdown of Hb → globulin (further broken down into amino acids) + haem (further broken down into bilirubin). This unconjugated bilirubin is then conjugated by the liver so it can be excreted in bile. In advanced liver disease, the liver retains its ability to conjugate bilirubin, but it cannot excrete it.
Albumin makes up more than half of the total protein in the blood. The remainder is made up by globulins (other blood proteins) which include α1-globulins (α1-antitrypsin), α2-globulins (α2-macroglobulin, haptoglobin), β-globulins (complement, transferrin), and γ-globulins (immunoglobulins). Albumin is synthesised by the liver and has a half-life of around 20 days. Hence, changes in levels happen over weeks.
↓albumin + ↓total protein = cirrhosis, nephrotic syndrome, chronic inflammation, protein-losing enteropathy, alcoholism, protein malnutrition/malabsorption
↓albumin + normal total protein = infection (albumin is a negative acute phase protein)
↓albumin + ↑ total protein = myeloma, Waldenström’s
PT/INR depend on clotting factors and fibrinogen which are synthesised by the liver. Some clotting factors have short half-lives (e.g. 6-8 hours) so changes can occur rapidly.
A 17 year old student presents with a fever and sore throat. He has cervical lymphadenopathy. His full blood count shows a lymphocytosis. Liver function tests reveal: ALT 1020, ALP 130, Bilirubin 27, Albumin 36.
Which pattern of LFT derangement is present?
Which further tests would you consider?
What is the likely diagnosis?
How would you manage the patient?
A 20 year old female with severe depression and bipolar disorder presented to the acute medical unit after a paracetamol overdose. Her paracetamol level is checked and is over the treatment line. Her ALT is 62 but her other liver function tests are normal.
Which treatment would you administer?
Which two specific blood tests are the most important to check at the end of the infusion?
If the patient refused the treatment and tried to leave, what would you do? She seems to understand the risks of the decision.
A 54 year old who drinks 1L vodka daily, presents with vomiting. On examination, he seems to be tremulous and is confused. He has large volume ascites. His blood tests are taken and his liver function tests are as follows: ALT 122, ALP 22, Bilirubin 120, Albumin 22. His coagulation test reveals: INR 3.0. His renal function test reveals: Na+ 128, K+ 4, Ur 6, Cr 190.
What do you think is going on?
What is your initial management?
An ascitic fluid aspirate is taken and the ascitic white cell count is raised. What are you concerned about and what additional treatments would you administer?