Interactive MCQ4

[The reader]

Salam everybody,

Read the following case and think about the answers. Make this a useful learning opportunity for yourself by going back and read about the subject. Feel free to ask anyone about the answer, but kindly do not disturb us by mentioning names and someone said so and so while other doctor said so and so. What I like to see instead is someone mentioning a study in 2004 said so and so or an abstract said so and so. Remember this is a scientific talk not old people talks or a coffee shop talks!!


*On a routine physical checkup for a 55 year old apparently healthy person, ALT = 85, AST= 104 and the rest of liver enzymes and CBC were entirly normal. The patient is not diabetic nor hypertensive. He smokes 1/2 pack of cigaretes per day for the last 20 years. He travells frequently as part of his job as a businessman and admits trace alcohol consumption socially but no sexual contacts away from his marrage. He has no family history of chronic liver diseases. Physical examination apart from nicotine staining was entirly normal.

What is your next step of action?

A) Perform US of the abdomen to assess the liver for focal lesions.
B) Send for 24 hour urine copper, ceruloplasmin level, Ferritin, iron/TIBC levels, ANA, ASMA.
C) Send first for hepatitis viral serology including Anti-HCV, HBsAG, and IgM anti-HBc.
D) Repeate testing after one month of complete discontinuation of alcohol and any suspected medications.
C)Perform liver biopsy.

Good luck

[MAJ]

Ok Doctor

Let`s start

The patient seems to be chronically drinking alcohol since long time , and considering the other given data in the case , first of all i`ll put in my mind Alcoholic Hepatitis .

And accordingly ,

Choice A is not indicated in all cases to do a radiological study unless there is clear data says yes we have to do although it is non expensive and easy to do it , but there is nothing from Hx And Ex giving a picture of liver cirrosis , portal hypertension or gall ston ….

Choice B also i`ll not chose it , because it is not a picture suggesting an autoimmune hepatitis in which the patient onset symptoms comes more sever with nausea, malise, anorexia and fatigue and also in young and middle age group most likely to come in while in this case , the patient is elderly one .

Choice D , what I know that the alcoholic hepatitis can be reversible condition but I do`nt know actually is it in one months or more to repeat the investigation after discontinuing the medication ???

Choice C also too advanced to do it at this stage .

So , i`ll go immediately first for choice C to exclude the viral hepatitis , screening for it , I think it is the most likely one to look for at this stage although there is no data in the Hx or Ex says that there is source of this infection BUT still I can`t exclude it especially he is travelling alot .

I hope it is a good trial , although I think there is also a trick for smoking point .


Waiting for you doctor .

[Dr.wrood2004]

Hi All

i tried to look for a study corellate liver disease with smoking .. but i couldnt .. i will try again later on...

the mild elevation of AST and ALT could be aclue for alcoholic liver hepatitis.. especially the milder forms which my present without symptoms or sign's apart of elevated liver enzyme..
so, liver US and biopsy will help us more in the diagnosis

anyway i will start with the simple test i will do it if i faced a high liver enzyme..

So, intially ... i will exclude viral hepatitis..
so i am agree with Dr.Maj that the answer is number C


thanks Doctor for such an interaction :)

[DR.KNIGHT]

الحمد لله والصلاة والسلام على اسرف الانبياء والمرسلين اما بعد:-

I am gonna to talk first about the exclusions that I have know then I will answer the case cinareo but I don`t know if it is right or wrong but I will try :

A) Is excluded because US of the abdomen is just to confirm our diagnosis in 90% diagnosed patient from full history and examination that could give us a clue about sever disease

B) We don`t need to perform ceruloplasmin level unless there is fulminant hapatitis. Also Ferritin, iron/TIBC levels unless there is chronic liver disease

C) I think the patient didn`t give us any information related to viral hepatitis

E) Is excluded bacause liver biopsy could be in advanced cases as my friend says

:wooow: THAT IS MY ANSWER AND I HOPE TO BE RIGHT

D) I think is the right answer because the patient could have mild alcoholic hepatitis

[reda0007]

Assalmu Alykom

it is really sensitive case as it is coming up from routine physical check up

and the patient is really in the early stage of the disease

even that the P/E is entirly normal

Okay this is very good as being an early presentation not as being a disease ofcourse

really hope to find such a presentation here in our country although no routine physical check up regretfully

okay i mean no routine physical check up applied widely

anyway

Masha ALLAH the doctors have discussed the case very well

okay i will really put trace alcohol consumption in focus :?:

if the patient was consuming large volume of alcohol then it would be usual to get liver diseade

but being normal otherwise and no risk factors for getting viral hepatitis

i will choose number D : reapeat the test after a month and after discontinuation of alcohol .

.......


okay i might change the choosen answer in a next reply

سبحان الله

so i will not submit the answer sheet now :45:

okay

salam for today

[al-jazi]

assalam alykom
thank u (the reader)

we look to +ve things
1-ALT AST elevated
2-smoker and alcholic

our aim in in this case (what is the cause of elevation of (ALT and AST) to start proper treatment .

so
the answr is (C ) viral serology is the right answer because we cannot exclude viral hepatitis in this case until if there is no history of risk factors of viral hepatits . and also viral hepatits in many cases maight be asymptomatic as in this case .
thank u agin (the reader)

[The reader]

Congratulations to MAJ and Dr.KNIGHT for the scientific tackling of the case where you look at the positives and negatives, what does go with this and what does not, why this is possible and that is impossible, why this information was provided and what it's relation to the correct answer. Our objective here is not only to get the right answer but to learn how did we get it and how to write scientific reasonings.

Good reasoning by the others(wrood and al-jazi). One comment for reda007, finding of the unexpected is common in medicine and you have to know as a clinicain what to do with it. We are not in an epidemiological session to look at what is common in our society! There is a well known entity described in the literature (and even books) called asymptomatic elevation of liver enzymes. Have you heared about this? OK it is the time to know it as you will see it in your practice.

(C) viral hepatitis serology is NOT the right answer.

So what could it be??

[Cardiac Arrest]

i have an answer


but i am not 100% sure


i will read more to confirm it

and i will put my answer here with explanation

[dr_messo]

assalamu alikum

What is your next step of action?

A) Perform US of the abdomen to assess the liver for focal lesions.
it will not show any thing .


B) Send for 24 hour urine copper, ceruloplasmin level, Ferritin, iron/TIBC levels, ANA, ASMA.
no , cuz other liver enzymes & CBC are normal & no evidince of Auto immune Disease .

C) Send first for hepatitis viral serology including Anti-HCV, HBsAG, and IgM anti-HBc.

i will exclude it because there is no Hx of sexual contact altho he is travelling but i think as he is a bussiness man his food should prepared well & clean .

D) Repeate testing after one month of complete discontinuation of alcohol and any suspected medications.

i will go for this cuz if the test were repaeated after one month & the enzymes back to normal that means the Alcohol is the cause .

C)Perform liver biopsy.

invasive procedure & no need to do it right now .

[Cardiac Arrest]

Cecil Textbook of Medicine - 22nd Edition ... www.Cecilmedicine.com

APPROACH TO THE ASYMPTOMATIC PATIENT WITH ABNORMAL LIVER TESTS

The apparently healthy patient with an isolated abnormality of the aminotransferase or alkaline phosphatase levels requires careful evaluation to identify any underlying disease while avoiding unneeded testing. Often, no significant disease is found despite extensive evaluation. Common causes of abnormal enzyme tests include obesity, alcohol consumption, chronic hepatitis C, steatohepatitis, bone disease, and muscle injury.


page 906
Epidemiologic data suggest that up to 25% of asymptomatic adult Americans have a mild to moderate elevation of aminotransferase levels. The incidental discovery of such abnormalities is currently the most frequent means by which liver disease is first recognized. Whereas up to one third of such patients have no elevation on subsequent testing, many others prove to have steatohepatitis (Chapter 155) or chronic hepatitis C (Chapter 152) (Fig. 149-4). Further evaluation is generally indicated only in patients with persistent abnormalities. Initial screening should include a careful history of exposure to hepatotoxins (alcohol, prescription drugs, over-the-counter medications, herbs, chemicals, and occupational exposures). If the abnormal test was an AST determination, a hepatic origin for the enzyme elevation should be confirmed with an ALT determination. If the ALT is normal, a muscle source is likely. If the ALT level is abnormal, the patient should be screened serologically for hepatitis B and C; young women should also be screened for markers of autoimmune liver disease. Older persons should be screened for hemochromatosis with an iron and transferrin level (Chapter 225), whereas younger persons should be screened with ceruloplasmin and urine copper for Wilson's disease (Chapter 224). If these tests are negative, screening for alpha1-antitrypsin deficiency is indicated (Chapter 85). Malaria (Chapter 392), schistosomiasis (Chapter 402), and other parasitic diseases should be considered in appropriate settings. A substantial fraction of patients prove to have fatty liver, with or without nonalcoholic steatonecrosis (NASH; Chapter 155). AST abnormalities caused by alcohol-induced steatosis should become normal with several weeks of abstinence. If the abnormalities persist for 6 to 12 months without an apparent cause, liver biopsy should be considered.



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[The patient with slightly increased liver function tests] ... www.Pubmed.com
Link: http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15745378


[Article in German]

Maier KP.

Fachbereich Gastroenterologie, Akademisches Lehrkrankenhaus der Universitat Tubingen, Stadtische Kliniken Esslingen. kp.maier@kliniken-es.de

The availability of serum blood chemistries for screening both symptomatic and asymptomatic patients has resulted in a marked increase in the number of abnormal liver chemistry tests that must be interpreted by physicians. Usually the first step in the evaluation of a patient with elevated liver enzymes is to repeat the test to confirm the result. If the result is still abnormal, it seems wise to differentiate between a predominant "necrotic pattern" of liver chemistry, as indicated by an elevation of ALT- or AST-activity or a predominant "cholestatic pattern", as indicated by elevated activities of g-GT and alkaline phosphatase. In patients with elevated serum amino transferases hepatic diseases should be excluded primarily with non-invasive serologic tests. The most common causes of elevated amino transferase levels are chronic hepatitis B and C, autoimmunhepatitis, non-alcoholic steatohepatitis, hemochromatosis, Wilson-disease and (only recently recognized) celiac sprue. In the case of a dominant "cholestatic pattern", primary biliary cirrhosis, primary sclerosing cholangitis, but also drugs and granulomatose hepatitis must be excluded. If non-invasive serologic studies remain inconclusive, ultrasound, mini-laparoscopy and liver biopsy will help to establish the final diagnoses.

PMID: 15745378 [PubMed - in process]


=============================================

www.Uptodate.com

Approach to the patient with abnormal liver function tests

I recommend for you to read the whole subject in the link
http://www.utdol.com/application/topic.asp?file=hep_dis/14684

EPIDEMIOLOGY — Abnormal LFTs are frequently detected in asymptomatic patients since many screening test panels now routinely include them [1]. Studies evaluating the clinical significance of these abnormalities have produced variable findings, although most have demonstrated that serious underlying liver disease is uncommon. The differences among individual studies reflects variation in the prevalence of liver disease in the populations that have been studied and the degree to which an underlying cause of the abnormalities was sought. Advances in the noninvasive tests to identify the cause of liver disease have permitted a greater understanding of the spectrum of liver disease encountered in various patient populations. The following examples illustrate some of the findings:

Abnormal serum aminotransferase levels (ALT >2.25 SD above normal; >55 IU/L) were detected in 99 of 19,877 (0.5 percent) Air Force recruits beginning basic training [2]. Of these, a cause was found in only 12 (including chronic hepatitis B and C, autoimmune hepatitis, and cholelithiasis). No specific diagnosis was established in the remaining 87 patients.

The diagnoses observed in two studies that included a total of 249 blood donors with abnormal serum ALT values included [3,4]: alcoholic liver disease (11 to 48 percent); fatty liver (22 to 56 percent); hepatitis C (17 to 20 percent; miscellaneous causes (4 to 8 percent); and no specific diagnosis (2 to 9 percent).

Another study focused on 81 of 1124 patients who were referred for abnormal serum aminotransferase levels in whom a diagnosis could not be inferred noninvasively [5]. A liver biopsy revealed steatosis or steatohepatitis in the majority of patients (84 percent); six patients had fibrosis or cirrhosis and eight had normal histologic findings.


One of the most recent studies included 354 patients who underwent a liver biopsy to investigate abnormal LFTs (defined as an alanine aminotransferase, gamma glutamyl transferase, or alkaline phosphatase more than twice the upper limit of normal for at least six months) [6]. Patients with clinical or serologic features suggesting a specific diagnosis were excluded. The most frequent finding on liver biopsy was nonalcoholic steatohepatitis or fatty liver (66 percent). The authors considered information on the biopsy to be important for directing management in 18 percent of patients. In addition, three families were entered into screening programs for inheritable liver disease.


Several conclusions can be derived from the above observations. First, a diagnosis can be established noninvasively in the vast majority of patients with abnormal LFTs. Second, appropriate testing can be guided by the pretest probability of specific forms of liver disease. Third, the majority of patients in whom the diagnosis remains unclear after obtaining a history and laboratory testing will have alcoholic liver disease, steatosis, or steatohepatitis.

It is important to emphasize that false positive results are more likely in patients who have a low pretest probability of having liver disease. This is a particular concern when abnormal LFTs are detected as part of a panel of laboratory tests drawn for other reasons. Normal test reference values are usually arbitrarily defined as those occurring within two standard deviations from the mean. As a result, 5 percent of healthy individuals who have a single screening test will have an abnormal result (2.5 percent will have an abnormally high result). As more tests are ordered, the likelihood of a false positive test increases; a screening panel containing 20 independent tests in a patient with no disease will yield at least one abnormal result 64 percent of the time (show table 1).

The sensitivity and specificity of the serum aminotransferases (particularly serum ALT) for discriminating those with and without liver disease depends upon the cutoff values chosen to define an abnormal test. At lease two large studies suggested that the cutoff values should be adjusted for gender and body mass index [7,8]. However, most patients identified with the lower cutoff values had only mild liver disease or no identifiable cause of the abnormal laboratory values. Thus, the overall benefit of the proposed modifications is unclear since it would translate into a large increase in the absolute numbers of patients who would require evaluation for an uncertain clinical benefit [9].


==============================================
INTERPRETATION OF ABNORMAL LIVER CHEMISTRY TESTS — The range of normal laboratory values for serum biochemical tests is defined as the mean of the distribution ± 2 standard deviations of a presumably representative healthy population. By definition, 2.5 percent of healthy individuals will therefore have an abnormal elevation of a given liver chemistry test and, in fact, a normal value does not completely exclude the presence of hepatic disease. The interpretation of all abnormal liver chemistries must be taken in the clinical context of a given patient. The initial evaluation of abnormal liver tests includes a detailed history, inventory of medications (including vitamins, herbs, over-the-counter drugs, etc.), and a physical examination. This should include an assessment of the patient's risk factors for liver disease, medications, alcohol consumption, comorbid conditions, and signs and symptoms of hepatic disease. When findings from these indicate that one or more diagnostic considerations are likely, subsequent evaluation should be directed toward establishing these diagnoses, rather than following an algorithm. The algorithm approach is useful mainly when there are no clinical clues or when the suspected diagnosis cannot be verified. An abnormality of a specific serum liver chemistry test must be interpreted in the context of all clinical information and a decision about the need for further diagnostic evaluation and/or the appropriate evaluation can best be made based on the specific clinical scenario of the individual patient.

The evaluation of patients with alanine aminotransferase (ALT) and aspartate aminotransferase (AST) elevations is described in Figure 1 (show figure 1A-1B)
http://www.utdol.com/data/images/gast_pix/eval_ami.gif
. In patients with elevated serum aminotransferases, common hepatic diseases should be excluded with noninvasive serologic tests. If these tests are unremarkable, a decision regarding additional serologic testing versus observation should be based on the clinical scenario. If one elects observation, close clinical follow-up and serial serum liver chemistry testing is essential. If markedly elevated and/or persistent ALT and AST levels are noted, or if significant symptoms or evidence of chronic or decompensated liver disease are present, a more expeditious and complete initial diagnostic evaluation typically is warranted. Similarly, chronic ALT or AST elevations (six or more months) usually warrant additional serologic and radiologic evaluations and potentially a liver biopsy. Hyperbilirubinemia due to either hepatocellular, cholestatic, or metabolic diseases may occur, but persistent hyperbilirubinemia due to any of these etiologies likely warrants a more expeditious diagnostic evaluation.



==============================================Base d on what i read, although i got confused many times when reading uptodate

My first choice will be:
D) Repeate testing after one month of complete discontinuation of alcohol and any suspected medications.


A) Perform US of the abdomen to assess the liver for focal lesions.
I think we will not get much benifit from this!

B) Send for 24 hour urine copper, ceruloplasmin level, Ferritin, iron/TIBC levels, ANA, ASMA.
could be but not now
Why could be? he is an old man, we may exclude or approve hemochromatosis.
Wilson disease unlikely, he is 55 yera old!
Autoimmune hepatitis! if women i will think about it more

C) Send first for hepatitis viral serology including Anti-HCV, HBsAG, and IgM anti-HBc.
Could be ... noninvasive but why to do it? just to exclude? with no H/O risk factors for hepatitis


E)Perform liver biopsy.
Invasive, at the end we can di it but not now !!

[H@SSOOM]

Salam


:waa: last night I revised my Kumar pocket about liver diseses then I finaly choosed c



but the dr said
(C) viral hepatitis serology is NOT the right answer.



:waa:




hmmmmmmmmmm I will read more and more and try again then I will write how was I am thinking



anyway even If I didn't choose the right answer , I ve got the benifit






hmmmmmm I can help u with this giud

http://www.uchsc.edu/gastro/2004_Pathophysiology/Chapt%201%20Liver%201.doc

it says


Aminotransferases (transaminases)


I. catalyze the transfer of an amino group (from alanine or aspartate) to alpha-ketoglutaric

acid

II. AST found in: liver, heart, muscle, kidney, brain, pancreas, lungs, WBC, RBC (descending

order)

III. ALT found : ”only” in the liver

IV. increased serum aminotransferase levels caused by injury to tissue rich in enzyme

V. catabolized by reticuloendothelial cells (not cleared by bile or urine)

Patterns of Aminotransferase Elevation



extremely high elevation of AST and ALT toxin

(50 - 1000x normal) ischemia

severe viral hepatitis

fulminant necrosis


mild elevation of AST and ALT most chronic viral hepatitis

(2 - 10x normal) alcoholic hepatitis

obstructive jaundice


fluctuating AST and ALT hepatitis C

(normal to 3x normal)


AST/ALT ratio > 2 alcoholic hepatitis

(ALT require pyridoxal phosphate for synthesis more than AST)

[WaLeeD]

AssaLaMu3LaiKuM..

UmmmMm..
Sorry for being late..
:12:



OK..

Choice A : It is very easy to be done.. But since No any sign or symptom of any cirrhotic or distructive liver is mentioned in the case.. So i'll escape it..


Choice B : I'll not do it.. for the same reson mentioned..


Choice C : Is already excluded..


Choice D : Yes I think it is the right next step for this case.. puting in mind that Alcohol may be the elevator here..


Choice E : Of course not.. it is invasive.. I'll not go for it as a next step..



But dears.. Although I trust my patient.. But I know how difficult is to seek his reponse in this manner.. Since Alcohol for them is just like water.. I'll not garantee that he will really stop drinking it.. it is not a copule of days.. it is ONE MONTH ( too much for him )..


Thanx dear The Reader..
waiting for your response..

[Cardiac Arrest]

Waiting for the answer :o:

[The reader]

Salam everybody,

I apologize for the delay.

The correct answer is (D) discontinue alcohol and any suspected hepatotoxic medications then repeate testing.

The reviews provided by cardiac arrest are excellent. If you go back to the flow chart from uptodate, you will see that we are still in the top of the algorithm. The first step is complete history and physical examination trying to identify risk factors for abnormal liver enzymes. Then the second is to stop alcohol and any hepatotoxic medications and then repeate testing. Alcohols can cause a wide range of liver enzymes abnormalities.( Acute alcoholic hepatitis gives you classically AST> 2 times ALT elevation. (AST is around twice the value of ALT)).

In this case we have to remeasure liver enzymes after stopping alcohol as the current elevation might be related to alcohol intake. If liver enzymes on repeate testing were normal you can stop at that stage. If they continued to be abnormal then you proceed with serological testing especially viral hepatitis as outlined in the flow chart above. You may end up with liver biopsy if no cause was identified. NASH (non-alcoholic steatohepatitis) is a diagnosis of exclusion and it may be the cause of the liver enzymes abnormalities especially in obese males.

Remember we are talking only about mild to moderate elevation of liver enzymes 2-3 times normal (some references mention 3-5 times normal). If you are dealing with above than that or what I call "the thousands club" where liver enzymes elevations are in thousands then you definitely need urgent investigation and hospital admission. The D.D for this club is not huge. Viral hepatitis and drugs are on the top, then hypoxic liver damage and CHF.

Congratulations for those who got the right answer. Hard luck for the rest.

I hope that you have enjoyed working up this case.

Any comments....

[Cardiac Arrest]

Wonderful



Thanx Dr.Hani for these interactive MCQs

I really gain alot of informations

and i learn many things

We are waiting for the next MCQ :eye:

I learned also that books are not enough
we have to search and search :eye:
read more and much more

Regards,

[H@SSOOM]

Thanx dr hani 4 the nice discussion


I ve got the answer D but after applying a good effort and doing many mistakes:o: :o:

and this is the beauty becasue mistakes here are recommended but infact
I revised many things according to the Liver and Biliary system which helped me very nicely in the next day in the surgical discussion of biliary diseases



hmmmmmmm what I want to add
this type of qustion is confusing sometimes and even u we selected the answer , we still don't know are we write or wrong

I've just changed from C to D when u said c is wrong

some of the answers are not wrong but ,,, incompeletly right




excuse me but I know that u don't like to talk about the exams
but if we faced such questions on the exams papers " of course we will like in Canadian exams or Saudi board" so what is ur advice then???


you know there will be no time to think because ather 99 similar question are waiting

and evey one saying ANA :LL:




so please tell us from ur expericne what is the proper methods of learning how to deal with these question

practice for example??????
or choose the answer and don't look back or don't revise??
any special books?
or any othe suggestions



finaly in the next case if you can tell us about the date of explaning the right answer it will be very nice and more effective



& thank u very much for communication with us

[The reader]

Thanks Hussam for raising this important issue.

Practice on MCQs books is the quick answer to you. The best books available are USMLE step 2 and 3.

We have to understand very basic concept about learning. There is factual recall of knoweledge - superficial learning, and there is integration of information which will lead to analysis, synthesis, creativity, thinking and ultimately a change in attitude - deep learning.

Our problem is that we have been taught, unfortunately, in a very superficial approach. To tell you the truth, we as learners, including most of your teachers!, don't like higher mental functions like thinking, discussions, analysis and challenges in ideas. These skills were not required from us as students and this is exactly what MCQs are looking for!!

Now what you need to do to imrove your skills in MCQs?

Solving MCQs during your routine studying time should be a well standard approach for you! It is not only reading your textbook to cover your lectures (secondary school approach - the most common approach among almost all medical schools here), you have to test your knowledge, you have to synthesise the information you have gathered from your readings, you have to use, yes use these information.

For sure solving MCQs is not the only way to improve your higher mental functions in medicine. There many ways and you will be surprised to know them: explaining what have you learned to your friends, seeing new patients with the disease that you have read about, carrying a difficult concept to your teacher or a friend and asking him about it. Simply talk..just talk to your friends about the liver enzymes that you read last night and what was the intersting and new information that you learned, quiz your frinds and let them quiz you! tell them I have a question for you and ask them... and so on.

We have to take learning from its superficial, rigid, unpleasant and uninteresting experience to its bright face with deep, pleasant, interesting, enjoyable experience. This is should be a way of life! It is an attitude changing process!

For a reason the scientist "Al-Alem" in our islam is way better than
Al-Abed. Even the whales in the sea is praying for him. This scientist is defeintely not only the Shareah Alem, he/she is anyone who follows this deep approach to learning!

My regards to you,

[dr_messo]

really doctor

we need to change our way of thinking & studying


i felt what u r talking about when i start reading form USMLE2

preparing for the evaluation exam of the MCC


it was extreemly diffrent way of study


really it was intersting

[Dr.wrood2004]

salam to all

thank you so much dr.hani for this discussion ..
I got many things ..

1st to not be in hurry in our decision and just to way the risk of harm and the risk of un-necessary coast

2and that not any mild elevation of the chemistry figures need an urgent or invasive investigation.

3rd we really need further reading and wide scope to look for the thing that we faced in real practical medicine to save ourselves and the patients..

it was really enjoyable

thanks