Investigation of liver and biliary tract diseases Clinical biochemistry, Autumn 2020 Lenka Gescheidtová, lenka.gescheidtova@mou.cz Liver is large… ♀ 1200 g – 1400 g ♂ 1400 g – 1800 g ♀ 1100 g – 1200 g ♂ 1300 g – 1400 g ♀ 1000 g – 1500 g ♂ 1500 g – 1900 g Liver and biliary ducts…. ….one functional unit Hepatobiliary system Extrahepatic obstruction https://drmagaziner.com/wp-content/uploads/2020/03/liver.jpg Intrahepatic obstruction Hepatic circulation - macrocirculation https://ib.bioninja.com.au/options/option-d-human-physiology/d3-functions-of-the- liver/liver-blood-flow.html Functional unit - lobule https://en.wikipedia.org/wiki/Liver#/media/File:Hepatic_structure2.svg Hepatic lobule microcirculation Liver function: • metabolism of all nutrients • proteosyntesis • energy storage • vitamins, micronutrients and iron storage • blood reservoir • estramedullary hematopoises • detoxication function – xenobiotics, mainly metabolic waste = urea synthesis, bilirubin secretion • bile production (digestive and detox function) Základní laboratorní vyšetření hepatobilárního systému: Charakteristika testu Analyt Testy odrážející integritu hepatocytů ALT, AST Testy odrážející poruchy na úrovni žlučovodů a kanalikulárního pólu jaterní buňky ALP, GGT Testy měřící proteosyntetickou kapacitu jater albumin, prealbumin, cholinesterasa, koagulační faktory – měří se nepřímo pomocí koagulačních časů /hlavně INR/ Laboratorní diagnostika žloutenek bilirubin (celkový, konjugovaný, nekonjugovaný), žlučové kyseliny Testy na specifické jaterní choroby S-Fe, transferrin, ferritin (hemochromatóza), S-Cu, ceruloplazmin (Wilsonova nemoc), U-porfobilinogen, U-ALA (porfyrie) Testy na hodnocení vážnosti jaterní fibrózy S-kyselina hyaluronová, PIIINP, TIMP1 Biochemický ústav LF MU – 2020 2/12 Základní biochemická vyšetření = součást vstupního vyšetření pacienta Specializovaná vyšetření, vyšetřují se za specifických podmínek Laboratory tests of hepatobiliary system - overview Charactetistics Parameters Tests indicative of hepatocyte integrity ALT, AST Tests indicative of disorders at the level of bile duct system and the canalicular pole of hepatocytes ALP, GGT Tests measuring protein synthesis by the liver albumin, prealbumin, cholinesterase, coagulation factors – indirect measurement by coagulation time /PT-ratio (INR)/ Differential diagnostics of jaundice bilirubin: total, conjugated (=direct), unconjugated, bile acids Laboratory tests for the diagnosis of specific hepatic diseases S-Fe, transferrin, ferritin (hemochromatosis), S-Cu, ceruloplasmin (Wilson‘s diseases), U-porfobilinogen, U-ALA (porfyria) Tests indicative the severity of hepatic fibrosis S-tissue inhibitor of metalloproteinases 1 (TIMP-1), aminoterminal propeptide of type III procollagen (PIIINP) and hyaluronic acid (HA) Department of Biochemistry, MUNI – 2020 2/12 Basic laboratory tests - statim Specialized tests Male, *1946 (74 years) Current disease: coming to the surgical clinic for gradually worsening abdominal pain for about 7 days, loss of appetite, lethargy, jaundice, is subfebrile, no vomiting. Baseline lab test Parameter Unit Ref. range Value CREATININ umol/l 65 - 108 124 eGFRepi ml/s 1,1 - 2 0.82 UREA mmol/l up 8,9 10.4 ALBUMIB g/l 39 - 49 31 TOTAL PROTEIN g/l 70 - 86 69 GLUCOSE mmol/l 4,6 - 6,1 8.3 Na+ mmol/l 137 - 145 132 K+ mmol/l 3,5 - 5,1 3.8 CL- mmol/l 100 - 108 94 AST ukat/l 0,29 - 0,72 3.69 ALT ukat/l 0,22 - 1,09 5.64 ALP ukat/l 0,67 - 1,64 2.71 GGT ukat/l 0,27 - 1,56 7.27 BILIRUBIN-total umol/l up 22 132 BILIRUBIN-direct umol/l up to 5 CRP mg/l up 11 293.6 What value would you expect, if the patient had jaundice ?? BILIRUBIN-total umol/l do 22 132 BILIRUBIN-direct umol/l do 5 What value would you expect, if the patient had jaundice ?? a) 4 umol/l b) 151 umol/l c) 109 umol/l BILIRUBIN-celk. umol/l do 22 132 BILIRUBIN-přímý umol/l do 5 What value would you expect, if the patient had jaundice ?? a) 4 umol/l b) 151 umol/l c) 109 umol/l Baseline lab tests Parameter Unit Ref. range Value CREATININ umol/l 65 - 108 124 eGFRepi ml/s 1,1 - 2 0.82 UREA mmol/l up 8,9 10.4 ALBUMIB g/l 39 - 49 31 TOTAL PROTEIN g/l 70 - 86 69 GLUCOSE mmol/l 4,6 - 6,1 8.3 Na+ mmol/l 137 - 145 132 K+ mmol/l 3,5 - 5,1 3.8 CL- mmol/l 100 - 108 94 AST ukat/l 0,29 - 0,72 3.69 ALT ukat/l 0,22 - 1,09 5.64 ALP ukat/l 0,67 - 1,64 2.71 GGT ukat/l 0,27 - 1,56 7.27 BILIRUBIN-total umol/l up 22 132 BILIRUBIN-direct umol/l up to 5 109 CRP mg/l up 11 293.6 What is the diagnosis ?? What is the diagnosis ?? RES: The patient has biliary obstruction. Due to the high CRP and clinical symptoms with cholangitis. What caused the obstruction followed by cholangoitits? Male, *1946 (74 years) CC: coming to the surgical clinic for gradually worsening abdominal pain for about 7 days, loss of appetite, lethargy, jaundice, is subfebrile, no vomiting. Anamnesis The patient was treated for carcinoma of ductus choledochus (dg. 2018), the radical surgery was not possible, he was treated by radiotherapy and received the stent into ductus choledochus. The disease has been in remission. The last oncological examination was before 3 months. Others: hypertension, benign prostate hyperplasia, DM II, stroke 2012, chronic atrial fibrillation Chronic pharmacotherapy: Verospiron 25 1x1, Solifenacin 10 1x1, Omnic 0,4 1x1, Rivodaron 200 1x1, Concor cor 5 1/2-0-0, Metformin 500 1-0-1 Biliary carcinoma progression. That was confirmed by CT of the abdomen. What caused the obstruction followed by cholangoitits? Icterus = jaundice - clinical sign, it manifests as skin and sclera yellowing - it appers, when bilirubinaemia is approx. 50 µmol/l or higher - cave !!! evaluation of jaundice is subjective, depending on the lighting in the room and the phototype of the patient Terminology: icterus = jaundice hepatitis = inflammation of liver infectious hepatitis = infectious jaundice Not every hyperbilirubinaemia is manifested as jaundice Not every hepatitis has jaundice Icteric serum • Serum icterity is caused by high bilirubinaemia • Icterity interferences with many analytical methods, but this interference is usually negligible • Substantial interference - bilirubinu > 200 µmol/l → inffluenced parameters: uric acid, creatinine, cholesterol, triacylglycerols, amylase HYPERBILIRUBINEMIA Hyperbilirubinemia Pathogenesis Bilirubin Urobilinogen Serum Urin e Urine predominantly unconjugated premicroso mal unconjugated bilirubin overproduction (hemolytic) ↑ unconj. - ↑ microsomal bilirubin conjugation disorders (Gilbert‘s sy, Crigler-Najjar sy) ↑ unconj. - - predominantly conjugated microsomal conjugated bilirubin secretion disorders (Dubin‘s sy, Rotor‘s sy) ↑ conj. ↑ cholestasis ↑ conj. ↑ - combined hyperbilirubinemia (conjugated + unconjugated) multiple mechanisms ↑ unconj. ↑ conj. ↑ ↑ / - Causes of jaundice • Exceeding the conjugation capacity of the liver in case of excessive hemolysis • Inflammation • Tumor • Acute liver failure (intoxication) • Inherited impairement of bilirubin excretion • Mechanical obstruction  intrahepatal  extrahepatal UNCONJUNGATED HYPERBILIRUBINEMIA CHOLESTASIS COMBINED HYPERBILIRUBINEMIA The patient is coming to you, because he suddenly turned yellow What is your next step ? The patient is coming to you, because he suddenly turned yellow Lab tests ? That is not definitely your first step The first step is anamnesis… How long the jaundice lasts? Have it occured first time? Which medication does the patient take? Did preceded abdominal pain? Other symptoms? Fatique, weight loss, anorexia? Other symptoms? Vomiting, diarhea, dark urine? The second step is physical examination… Splenomegaly? Hepatomegaly? Gynekomastia? Bruises? Foetor hepaticus? Kachexia? The third step are lab tests and imaging Anamnesis: PMH: hypothyreosis, appendectomy in childhood • 3/2017 dg. Adenocarcinoma of gall bladder, pT2 pN0 (0/1) M0,P1, G2, clin. st. II. ‒ surgery – resection jaterního lůžka žlučníku, histologicky bez známek reziduální malignity ‒ adjuvant CTx and RTx 12/2017 ‒ remission (= no disease signs), regular oncological examination every 6 months Medication: Letrox 75 mcg 1-0-0 SocHx: secretary, married GynHx: gravidity 2x, parturition 2x, menopause at 52 years Alergy: 0 CC: 7/2020 – routine oncological examination, no subjective symptoms, no weight loss, physical examination with no pathology, labs - substantial elevation of liver parameters Case report II - female, 58 years Parameter UNIT Reference range 7/2019 1/2020 7/2020 CREATININE umol/l 65-108 74 78 68 eGFRepi ml/s 1,1-2 1.29 1.2 1.41 UREA mmol/l do 8,9 5.2 6 4.8 ALBUMIN g/l 39-49 44 45 43 TOTAL PROTEIN g/l 70-86 73 72 75 GLUCOSE mmol/l 4,6-6,1 5.6 6 5.6 Na+ mmol/l 137-145 143 142 139 K+ mmol/l 3,5-5,1 4.7 4.2 4.3 CL- mmol/l 100-108 107 104 103 AST ukat/l 0,29-0,72 0.32 0.27 10.49 ALT ukat/l 0,22-1,09 0.41 0.35 19.2 ALP ukat/l 0,67-1,64 1.21 1.29 7.61 GGT ukat/l 0,27-1,56 1.04 1.01 14.46 LDH ukat/l 2,1-3,59 2.76 2.72 8.07 BILIRUBIN-tot. umol/l do 22 6 5 28 CA19-9 kU/l do 40 2.4 1.9 2.5 CEA ug/l do 4.6 2.1 1.9 2.6 Case report II - female, 58 years The patient has no symptoms, no clinical signs of the liver disease (no jaundice, no hepatomegaly) What is your next step? Serological hepatitis tests? Suspected alcoholism? Control laboratory per month? • You perform the CT examination of the abdomen and see this report: In the vicinity of the clamps after surgery in the hilum of the liver, there is a newly visible infiltrate of size 32x22mm, which acts as a local recurrence of the tumor. Bladder dilatation is also newly seen. pathways mainly centrally, choledochus 13 mm wide at the level of the hilum, further extrahepatically suppressed by the infiltrate described above. Conclusion: relapse of oncological disease. Case report II - female, 58 years Case report III - female, 24 years CC: sore throat 3 days, subfebrile about 37 ° CC, fatique, anorexia, abdominal pain PMHx: sideropenic anemia in puberty, otherwise healthy Medication: sine Abusus: non-smoker, alcohol – vine 2dl 3x per week Physical examination: Temp. 37.1°C BP 118/75 PF 88/min. BMI 21,5 Head and neck – throat redness, tonsils through an arch with white coatings and several pins, foetor ex ore - picture of streptococcal tonsillitis, pale conjunctiva, paler skin color, palpable occipital and sternocleidomastoideal lymph nodes Thorax – clear breathing, full and bright percussion, regular heart rate Abdomen – liver enlargement (exceeding 2 cm over the costal arch), feeling pain during palpation, palpable lymh nodes in both groins Female, *1995 (24 years) Parameter Unit Reference range 4.4.2019 11.4.2019 13.5.2019 10.7.2019 CREATININE umol/l 65-108 68 69 86 eGFRepi ml/s 1.1-2 1.81 1.78 1.36 UREA mmol/l do 8.9 2.5 5.1 4.6 ALBUMIN g/l 39-49 42 38 42 TOTAL PROTEIN g/l 70-86 77 82 76 GLUCOSE mmol/l 4.6-6.1 4.5 Na+ mmol/l 137-145 138 137 139 K+ mmol/l 3.5-5.1 3.7 4 3.6 CL- mmol/l 100-108 101 101 102 AST ukat/l 0.29-0.72 3.33 0.79 0.33 0.32 ALT ukat/l 0.22-1.09 5.41 1.35 0.28 0.28 ALP ukat/l 0.67-1.64 3.62 2.14 0.77 GGT ukat/l 0.27-1.56 4.87 2.69 0.59 0.34 BILIRUBIN-tot. umol/l do 22 6 3 6 7 CRP mg/l do 11 23.7 74.1 9.3 17 Case report III - Female, 24 years, laboratory - biochemistry Parameter Jednotka Referenční rozmezí 4.4.2019 11.4.2019 13.5.2019 10.7.2019 RED blood cells x 10*12/l 3.8 - 5.2 4.52 4.57 4.39 4.43 WHITE blood cells x 10*9/l 4 - 10 38.43 !!! 15.3 9.48 8.27 HEMOGLOBIN g/l 120 - 160 130 130 127 129 HEMATOCRIT 0.35 – 0.47 0.383 0.385 0.37 0.373 PLATELETS x 10*9/l 150 - 400 208 306 273 266 NEUTROPHILS 0.45 - 0.70 0.145 0.213 0.432 0.46 EOSINOPHILS 0.00 - 0.05 0.001 0.007 0.034 0.046 BASOPHILS 0.00 - 0.02 0.002 0.012 0.006 0.006 LYMPHOCYTES 0.20 - 0.45 nelze 0.661 0.437 0.4 MONOCYTES 0.02 - 0.12 nelze 0.107 0.091 0.088 NEUTRO-count x 10*9/l 2 - 7 5.53 3.26 4.1 3.8 EOSINO-count x 10*9/l 0.0 - 0.5 0.04 0.11 0.32 0.38 BASO-count x 10*9/l 0.0 - 0.2 0.09 0.18 0.06 0.05 MONO-count x 10*9/l 0.08 -1.20 nelze 1.63 0.86 0.73 LYMPHO-count x 10*9/l 0.80 - 4.00 nelze 10.12 4.14 3.31 IMMATURE GRAN. 0.000 - 0.006 0.5 0.3 0.2 0.1 IMMATURE GRAN-count x 10*9/l 0.00 - 0.04 0.18 0.04 0.02 0.01 Case report III - Female, 24 years, laboratory - hematology • blood smear layer - atypical lymphocytes - the cells are large with fine chromitne, high N/C rate, prominent nucleoli → look like blasts Case report III - Female, 24 years, laboratory - microscopy What is the diagnosis ?? Infection??Leukemia ?? Leukemia - signs and symptoms Fatique Dyspnea Bleeding, bruises Palor skin Weight loss Fever Prolonged infections Abdominal pain (hepatomegaly and/or splenomegaly) Enlarged lymph nodes current patient Nevertheless, it is clear from the laboratory examination that it is not leukemia… Parametr Jednotka Referenční rozmezí 4.4.2019 11.4.2019 13.5.2019 10.7.2019 ERYTROCYTES x 10*12/l 3.8 - 5.2 4.52 4.57 4.39 4.43 LEUKOCYTES x 10*9/l 4 - 10 38.43 !!! 15.3 9.48 8.27 HEMOGLOBIN g/l 120 - 160 130 130 127 129 HEMATOCRITE 0.35 – 0.47 0.383 0.385 0.37 0.373 TROMBOCYTES x 10*9/l 150 - 400 208 306 273 266 NEUTROPHIL-ratio 0.45 - 0.70 0.145 0.213 0.432 0.46 EOSINOPHIL-ratio 0.00 - 0.05 0.001 0.007 0.034 0.046 BASOPHIL-ratio 0.00 - 0.02 0.002 0.012 0.006 0.006 LYMPHOCYTE-ratio 0.20 - 0.45 nelze 0.661 0.437 0.4 MONOCYTE-ratio 0.02 - 0.12 nelze 0.107 0.091 0.088 NEUTROPHIL-abs. x 10*9/l 2 - 7 5.53 3.26 4.1 3.8 EOSINOPHIL-abs. x 10*9/l 0.0 - 0.5 0.04 0.11 0.32 0.38 BASOPHIL-abs. x 10*9/l 0.0 - 0.2 0.09 0.18 0.06 0.05 MONOCYTE-abs. x 10*9/l 0.08 -1.20 nelze 1.63 0.86 0.73 LYMPHOCYTE-abs. x 10*9/l 0.80 - 4.00 nelze 10.12 4.14 3.31 IMMATURE GRAN. 0.000 - 0.006 0.5 0.3 0.2 0.1 IMMATURE GRAN.-abs. x 10*9/l 0.00 - 0.04 0.18 0.04 0.02 0.01 It is highly unlikely that hemoglobin, trombocytes and neutrophils would be normal in acute leukemia Case report III - Female, 24 years, laboratory - microscopy Infectious mononucleosis • disease caused by primary infection with Epstein-Barr virus (EBV) • clinically similar to streptococcal angina, manifested by fever, sore throat, lymphadenopathy • other signs: hepatosplenomegaly, petechiae on the palate (Holz's symptom), swelling of the eyelids (Bass's symptom), rhinolalia, foetor ex ore, loss of appetite, general weakness • blood count: leukocytosis with lymphocytosis and monocytosis, large atypical lymphocytes, mild neutropenia or trombocytopenia are possible • liver tests: elevation of liver enzymes and LD (usually 2–3×, but also 10× or more) • specific confirmation of the diagnosis - EBV serology Ebstein-Barr Virus antibodies • serology = detection of specific antibodies against antigens: VCA (Viral Capsid Antigen), EA (Early Antigen), EBNA (Ebstein Baar Nuclear Antigen) Parameter Unit Reference range 4.4.2019 11.4.2019 13.5.2019 10.7.2019 CREATININE umol/l 65-108 68 69 86 eGFRepi ml/s 1.1-2 1.81 1.78 1.36 UREA mmol/l do 8.9 2.5 5.1 4.6 ALBUMIN g/l 39-49 42 38 42 TOTAL PROTEIN g/l 70-86 77 82 76 GLUCOSE mmol/l 4.6-6.1 4.5 Na+ mmol/l 137-145 138 137 139 K+ mmol/l 3.5-5.1 3.7 4 3.6 CL- mmol/l 100-108 101 101 102 AST ukat/l 0.29-0.72 3.33 0.79 0.33 0.32 ALT ukat/l 0.22-1.09 5.41 1.35 0.28 0.28 ALP ukat/l 0.67-1.64 3.62 2.14 0.77 GGT ukat/l 0.27-1.56 4.87 2.69 0.59 0.34 BILIRUBIN-tot. umol/l do 22 6 3 6 7 CRP mg/l do 11 23.7 74.1 9.3 17 Case report III - Female, 24 years, laboratory – biochemistry, control Parameter Jednotka Referenční rozmezí 4.4.2019 11.4.2019 13.5.2019 10.7.2019 RED blood cells x 10*12/l 3.8 - 5.2 4.52 4.57 4.39 4.43 WHITE blood cells x 10*9/l 4 - 10 38.43 !!! 15.3 9.48 8.27 HEMOGLOBIN g/l 120 - 160 130 130 127 129 HEMATOCRIT 0.35 – 0.47 0.383 0.385 0.37 0.373 PLATELETS x 10*9/l 150 - 400 208 306 273 266 NEUTROPHILS 0.45 - 0.70 0.145 0.213 0.432 0.46 EOSINOPHILS 0.00 - 0.05 0.001 0.007 0.034 0.046 BASOPHILS 0.00 - 0.02 0.002 0.012 0.006 0.006 LYMPHOCYTES 0.20 - 0.45 nelze 0.661 0.437 0.4 MONOCYTES 0.02 - 0.12 nelze 0.107 0.091 0.088 NEUTRO-count x 10*9/l 2 - 7 5.53 3.26 4.1 3.8 EOSINO-count x 10*9/l 0.0 - 0.5 0.04 0.11 0.32 0.38 BASO-count x 10*9/l 0.0 - 0.2 0.09 0.18 0.06 0.05 MONO-count x 10*9/l 0.08 -1.20 nelze 1.63 0.86 0.73 LYMPHO-count x 10*9/l 0.80 - 4.00 nelze 10.12 4.14 3.31 IMMATURE GRAN. 0.000 - 0.006 0.5 0.3 0.2 0.1 IMMATURE GRAN-count x 10*9/l 0.00 - 0.04 0.18 0.04 0.02 0.01 Case report III - Female, 24 years, laboratory – hematology, control Chronic liver disease https://www.arcr.niaaa.nih.gov/arcr382/images/article11-02.png Case report IV - female, 64 years CC: comes to the hospital for elective surgery- metastazectomy of the solitary metastasis in the liver HPI: adenocarcinoma col. desc., dg. 3 years ago - hemicolectomy was performed, adjuvant chemotherapy - remission for 3 years, last month solitary metastasis in liver has occured PMH: hypertension, DM II smoker, alcohol - vine 2dl/week SocHX: married, designer Parameter UNIT Reference range 09.06. 30.06. 01.07. 02.07. 03.07. 04.07. 06.07. CREATININE umol/l 65-108 53 40 eGFRepi ml/s 1,1-2 1.61 1.77 ALBUMIB g/l 39-49 42 TOTAL PROTEIN g/l 70-86 83 GLUCOSE mmol/l 4,6-6,1 6.6 8.1 5.5 7.6 6.4 5.8 Na+ mmol/l 137-145 134 135 136 135 136 135 134 K+ mmol/l 3,5-5,1 4.5 3.4 3.9 3.9 3.7 4.1 4.2 CL- mmol/l 100-108 96 101 103 100 101 101 97 AST ukat/l 0,29-0,72 0.47 10.49 8.86 4.82 2.74 1.29 ALT ukat/l 0,22-1,09 0.33 10.44 11.59 9.27 7.13 4.43 ALP ukat/l 0,67-1,64 2.19 1.78 2.01 2.27 2.78 4.03 GGT ukat/l 0,27-1,56 0.41 0.50 0.54 0.73 1.23 3.11 BILIRUBIN-tot. umol/l do 22 7 6 4 4 4 3 operation Case report IV - female, 64 years Case report V - female, 65 years CC: anemia, fatique and weight loss 5 kg / 3 months Lab. normocytic normochromic anemia Hgb 99 g/l ↓ MCV 85 fl N MCH 30 pg N RBC 3.3 x 1012/l ↓ Platelets 100 x 109/l ↓ WBC 5.1 x 109/l N OA: hypertension, DM II, hypercholesterolemia, DM II, dilatated cardiomyopathy, liver cirrhosis, sec. splenomegaly, sec. trombocytopenia, right breast carcinoma cured 3 years ago - in remission, FA: Stadamet 500mg 1-0-1 - dnes nebrala, Omeprazol 20mg 1-0-0, Verospiron 25mg 0-1-0, Kalium chloratum 500mg 2-1-1, Kalnormin 1-0-1, Furon 40mg 1/2-0-0, Sylimarin AL 50mg 1-0-1, Rivotril 0,5mg 0-0-1, Coryol 3,125mg 1-0-0, Torvazin 10mg 0-0-1, Alozex 1mg 1-0-0 Soc.Hx: divorced, living with her daughter, pensioner Phys. functions: urination without problems, stool is regular, sometimes problems with hemorrhoids (she had once blood on toilet paper) Case report V - female, 65 years Clinical examination: must include per rectum to check the hemorrhoids or to detect rectal bleeding (red blood) or gastric bleedeing (melena) Diagnostic-therapeutic plan: • gastrofibroscopy (esophageal varices? peptic ulcerations?) • rectoscopy (to reveal the internal hemorrhoids or rectal fissure) • USG - abdomen, X-ray - lung (metastases of breast carcinoma?) • colonoscopy (anemia can be caused by colorectal carcinoma) Case report V - female, 65 years • gastroscopy and rectoscopy - no pathology • USG abdomen • liver cirrhosis with suspected formation → CT abdomen → liver tumor infiltration → CT navigated biopsy → histology: Hepatocellular carcioma grade I Case report V - female, 65 years Parameter UNIT Reference range 4.6.2020 1.7.2020 3.7.2020 6.7.2020 7.7.2020 CREATININE umol/l 65-108 53 eGFRepi ml/s 1.1-2 1.61 UREA mmol/l do 8.9 4.3 ALBUMIN g/l 39-49 43 TOTAL PROTEIN g/l 70-86 83 GLUCOSE mmol/l 4.6-6.1 6.5 5.5 6.4 6.7 5.8 Na+ mmol/l 137-145 136 136 136 134 134 K+ mmol/l 3.5-5.1 4.6 3.9 3.7 4.2 4.1 CL- mmol/l 100-108 98 103 101 97 95 AST ukat/l 0.29-0.72 0.42 10.49 4.82 1.29 1.01 ALT ukat/l 0.22-1.09 0.33 10.44 9.27 4.43 3.39 ALP ukat/l 0.67-1.64 2.14 1.78 2.27 4.03 4.41 GGT ukat/l 0.27-1.56 0.41 0.5 0.73 3.11 3.73 BILIRUBIN-tot. umol/l do 22 5 6 4 3 3 LDH ukat/l 2,1-3,59 3.32 liver biopsy Case report V - female, 65 years baseline Clinical signs of liver cirrhosis sarcopenia caput medusae gynecomastia spider angiomata ascites intellect disorder fatique and performance loss „Non-alcoholic“ liver cirrhosis – causes • Chronic hepatitis - infectious, autoimmune • Primary biliary cirrhosis, primary sclerosing cholangitis • Long term biliary obstruction • Toxic liver damage - poisoning by paracetamol, mushrooms (Amanita phalloides) etc. • Metabolic diseases - Wilson's, hemochromatosis, porphyria, cystic fibrosis, α1-antitrypsin deficiency • Unclear etiology - so-called cryptogenic cirrhosis Child-Pugh classification for liver cirrhosis https://muggerboard.wordpress.com/2015/11/21/child-pugh-score/ How to evalute chronic liver disease? • histopatological classification via liver biopsy • biopsy is risky and not allways available (cause of related coagulopathy) Non-invasive scoring: • ELF score - tissue inhibitor of metalloproteinases 1 (TIMP-1), aminoterminal propeptide of type III procollagen (PIIINP) and hyaluronic acid (HA) • Fibrotest® - combination of 6 biochem. markers • NAFLD fibrosis score - based on ALT, AST, Alb, platelet count, BMI a age ELF (Enhanced Liver Firosis) score = monitoring of chronic liver damage https://www.lalpathlabs.com/blog/enhanced-liver-fibrosis/2015-12-29_1060/ CHILD PUGH vs. ELF SCORE Child Pugh classification • evaluation of remaining liver functions in patients with cirrhosis • does not include the histopathological staging ELF score • biochemical staging of liver fibrosis, can replace the biopsy (in some cases) • does not iclude the liver functions Thanks for your attention questions and requests lenka.gescheidtova@mou.cz ALCOHOL-FREE IPA 