If a patient has bilirubin 20 mg/dl, AST=313,, ALT=103 & GGT=44 IU/L. Most probable diagnosis is:
Ans: B (Alcoholic...) Here, in Q AST > ALT(>3 times)- so most probable diagnosis is alcoholic hepatitisNormal value ofy-glutamyl transferase is 051IU/L L.D of Alcoholic Fatty Liver & Alcoholic HepatitisTestCommentASTincreased two-to-sevenfold,<400U/ L,greater than ALTALTIncreased two to sevenfold .less than 400U/ LAST/ALTUsually >1GGTPBilirubin5Not specific to alcohol, easily inducible .elevated in all forms of fatty liverMay be markedly increased in alcoholic hepatitis despite modest elevation in alkaline phosphatasePMNlf> 5500/uL predicts severe alcoholic hepatitis when discriminant function >32PMN- Polymorphonuclear cellsSERUM ENZ\ MES Harrison 18th/2527-30# The normal range for aminotransferases varies widely among laboratories, but generally ranges from 10-40 U/L.# Any type of liver cell injury can cause modest elevations in the serum aminotransferases. Levels of up to 300 U/L are nonspecific and may be found in any type of liver disorder. Minimal ALT elevations in asymptomatic blood donors rarely indicate severe liver disease; studies have shown that fatty liver disease is the most likely explanation. Striking elevations--i.e,, aminotransferases >1000 U/L--occur almost exclusively in disorders associated with extensive hepatocellular injury such as (1) viral hepatitis, (2) ischemic liver injury (prolonged hypotension or acute heart failure), or (3) toxin- or drug-induced liver injury.The pattern of the aminotransferase elevation can be helpful diagnostically. In most acute hepatocellular disorders, the ALT is higher than or equal to the AST. While the AST:ALT ratio is typically less than 1 in patients with chronic viral hepatitis and non-alcoholic fatty liver disease, a number of groups have noted that as cirrhosis develops this ratio rises to greater than 1.An AST.ALT ratio >2:1 is suggestive, while a ratio >3:1 is highly suggestive of alcoholic liver disease. The AST in alcoholic liver disease is rarely >300 U/L, and the ALT is often normal. A low level of ALT in the serum is due to an alcohol-induced deficiency of pyridoxa! phosphate.The aminotransferases are usually not greatly elevated in obstructive jaun dice.Enzymes that Reflect Cholestasis# The activities of three enzymes--alkaline phosphatase, 5'-nucleotidase, and g-glutamyi transpeptidase (GGT')--are usually elevated in cholestasis.Reflecting its more diffuse localization in the liver, GGT elevation in serum is less specific for cholestasis than are elevations of alkaline phosphatase or 5'-nucleotidase. Some have advocated the use of GGT to identify patients with occult alcohol use. Its lack of specificity makes its use in this setting questionable.Table (Harrison 18th/2530): Liver Test Patterns in Hepatobiliary DisordersType of DisorderBilirubinAminotrans ferasesAlkaline PhosphataseAlbuminProthrombin TimeHemolysis/Gilbert's syndromeNormal to 86 umol/L (5 mg/ dL) 85% due to indirect fractions No bilirubinuriaNormalNormalNormalNormalAcute hepatocellular necrosis (viral and drug hepatitis, hepatotoxins, acute heart failure)Both fractions may be elevated Peak usually follows aminotransferases BilirubinuriaElevated, often >500 1U ALT >ASTNorma] to <3 times normal elevationNormalUsually normal. If >5X above control and not corrected by parenteral vitamin K, suggests poor prognosisChronic hepatocellular disordersBoth fractions may be elevated BilirubinuriaElevated, but usually <300 IUNormal to <3 times normal elevationOften decreasedOften prolonged Fails to correct with parenteral vitamin KAlcoholic hepatitis CirrhosisBoth fractions may be elevatedBilirubinuriaAST:ALT > 2 suggests alcoholic hepatitis or cirrhosisNormal to <3 times normal elevationOften decreasedOften prolonged Fails to correct with parenteral vitamin KIntra- and extra-hepatic cholestasis(Obstructive jaundice)Both fractions may be elevated' BilirubinuriaNormal to moderate elevation Rarely >500IUElevated, often >4 times normal elevationNormal, unless chronicNormalIf prolonged, will correct with parenteral vitamin KInfiltrative diseases (tumor, granuloma- ta); partial bile duct obstructionUsually normalNormal to slight elevationElevated, often >4 times normal elevationFractionate, or confirm liver origin with 5' nucleotidase or g glutamyl transpep- tidaseNormalNormalTable (CMDT):Causes of serum aminotransferase elevations.Mild Elevations (<5x normal)Severe Elevations (> 15 x normal)Hepatic: ALT-predominantChronic hepatitis B, C, DAcute viral hepatitis (A-E, EBV, CMV)Steatosis/steatoh epatitisH emochromatosisMedications/toxinsAutoimmune hepatitis a 1 Antitrypsin deficiencyWilson diseaseCeliac diseaseHepatic: AST-predominantAlcohol-related liver injury (AST:ALT > 2:1)CirrhosisNonhepaticStrenuous exerciseHemolysisMyopathyThyroid diseaseMacro-ASTAcute viral hepatitis (A-E, herpes)Medications/toxinsIschemic hepatitisAutoimmune hepatitisWilson diseaseAcute bile duct obstructionAcute Budd-Chiari syndromeHepatic artery ligation
Viral hepatitis
Alcoholic hepatitis
Billiary atresia
Drugs
Liver