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DR. Dr. Hanifah Oswari, Sp.

A(K)

S1 FKUI 1983-1989

Spesialis anak FKUI 1994-1999

Fellow Gastroenterology-hepatology and nutrition,
Royal Children’s Hospital, Brisbane, Australia,
2000-2001
Saat ini:

Konsultan Gastroenterohepatologi FKUI 2005

S3 Program studi Ilmu Kedokteran FKUI 2009

Staf Gastroenterohepatologi Anak FKUI
Tuesday, July 12, 2011
Abnormal liver function test:
how to evaluate
DR. Dr. Hanifah Oswari, Sp.A(K)
Pediatric Gastroentero-hepatologist
Faculty of Medicine, Cipto Mangunkusumo Hospital
Tuesday, July 12, 2011
Presentation
Tuesday, July 12, 2011
LFT
Liver Function
Test
Tuesday, July 12, 2011
BILIRUBIN
Alk Phosphatase
Gamma GT
80% heme
20% others
Tuesday, July 12, 2011
Albumin
Prothrombin time
Synthetic function
20 days
hours
Chronic process
Cirrhosis
Vit K def
significant hepatocellular dysfunction
Tuesday, July 12, 2011
Liver function test
Health of the liver
Tuesday, July 12, 2011
Liver function test
May be abnormal
Health of the liver
Tuesday, July 12, 2011
AST
Tuesday, July 12, 2011
AST
Cytoplasm Mitochondria
Tuesday, July 12, 2011
ALT
Cytoplasm
Tuesday, July 12, 2011
AP
Tuesday, July 12, 2011
Gamma GT
Newborn
6-7x adult
Tuesday, July 12, 2011
Age
Tuesday, July 12, 2011
Hepatocellular
Bile duct
ALT
AST
Bilirubin
GGT
Alk Phosp
Tuesday, July 12, 2011
Mild chronic elevation in serum aminotransferases
Tuesday, July 12, 2011
Mild chronic elevation in serum aminotransferases
< 4 ULN
> 6 months
one or both
> 2 ULN
Tuesday, July 12, 2011
Mild chronic elevation in serum aminotransferases
2 1 3 4
Tuesday, July 12, 2011
Mild chronic elevation in serum aminotransferases
Identify
most
common
cause of
liver
disease
Look for
non-
hepatic
causes
Identify
rarer
cause of
liver
disease
Liver
biopsy
2 1 3 4
Tuesday, July 12, 2011
Mild chronic elevation in serum aminotransferases
Identify
most
common
cause of
liver
disease
Drug/herbal
Hepatitis B
Hepatitis C
NAFLD
1
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Tuesday, July 12, 2011
Tuesday, July 12, 2011
Tuesday, July 12, 2011
Tuesday, July 12, 2011
Tuesday, July 12, 2011
hep-C hep-B
Tuesday, July 12, 2011
hep-B
HBsg
AntiHBc IgM
Tuesday, July 12, 2011
hep-C
AntiHCV
Tuesday, July 12, 2011
NAFLD
Tuesday, July 12, 2011
O
b
e
s
i
t
y
Tuesday, July 12, 2011
Tuesday, July 12, 2011
Tuesday, July 12, 2011
Mild chronic elevation in serum aminotransferases
Look for
non-
hepatic
causes
Muscle
disorders
Thyroid
disorders
2
Tuesday, July 12, 2011
Thyroid disorders
Tuesday, July 12, 2011
Thyroid disorders
TSH
FT4
Tuesday, July 12, 2011
Muscle disorders
Tuesday, July 12, 2011
Muscle disorders
Creatinin kinase
Tuesday, July 12, 2011
Mild chronic elevation in serum aminotransferases
Identify
rarer
cause of
LD
Autoimmune
hepatitis
Wilson’s
disease
3
Tuesday, July 12, 2011
Autoimmune hepatitis
Tuesday, July 12, 2011
Wilson’s disease
Tuesday, July 12, 2011
Mild chronic elevation in serum aminotransferases
observe in
ALT & AST
< 2 ULN
May be needed when
no etiology found +
ALT & AST
persistently
> 2 ULN
4
Tuesday, July 12, 2011
Bilirubin
Tuesday, July 12, 2011
B
i
l
i
r
u
b
i
n
Total
Direk
Indirek
20%total
>1 mg/dl
Tuesday, July 12, 2011
Uptake
Conjugation
Excretion
Tuesday, July 12, 2011
Cholestasis
Intrahepatik Extrahepatik
Biliary atresia
20%total
>1 mg/dl
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Tuesday, July 12, 2011
Tuesday, July 12, 2011
Tuesday, July 12, 2011
Sign & Symptoms
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Sign & Symptoms
Tuesday, July 12, 2011
Isolated hyperbilirubinemia
Unconjugated
Tuesday, July 12, 2011
Isolated hyperbilirubinemia
Bilirubin
over
production
Hemolysis
Unconjugated
Tuesday, July 12, 2011
Isolated hyperbilirubinemia
Bilirubin
over
production
Hemolysis
Impaired
hepatic
bilirubin
uptake
Hepatic blood flow
Drugs
Unconjugated
Tuesday, July 12, 2011
Isolated hyperbilirubinemia
Bilirubin
over
production
Hemolysis
Impaired
hepatic
bilirubin
uptake
Hepatic blood flow
Drugs
Unconjugated
Impaired
hepatic
bilirubin
conjugation
Gilbert’s disease
Crigler-Najjar
Drugs
Hyperthyroidism
Tuesday, July 12, 2011
Isolated hyperbilirubinemia
Conjugated
Tuesday, July 12, 2011
Isolated hyperbilirubinemia
Conjugated
Dubin-Johnson
syndrome
Tuesday, July 12, 2011
Isolated hyperbilirubinemia
Conjugated
Dubin-Johnson
syndrome
Rotor
syndrome
Tuesday, July 12, 2011
Isolated hyperbilirubinemia
Conjugated
Dubin-Johnson
syndrome
Rotor
syndrome
direct bili + 50% total AND normal other LFT’s
Tuesday, July 12, 2011
Conclusion
Abnormal LFT

Not directly to liver function

2 types: hepatocellular & cholestasis

High aminotransferases-steps approach

Cholestasis-don’t miss biliary atresia

Isolated unconjugated hyperbilirubinemia:
hemolysis-impaired uptake or impaired
conjugation

Isolated conjugated-Rotor & Dubin Johnson
remember
Tuesday, July 12, 2011
Tuesday, July 12, 2011
Please
Tuesday, July 12, 2011
Exercise

Bilirubin total 10 mg/dl

Bilirubin direk 1,5 mg/dl
Tuesday, July 12, 2011
Exercise

Bilirubin total 20 mg/dl

Bilirubin direk 3 mg/dl
Tuesday, July 12, 2011
Exercise

Bilirubin total 25 mg/dl

Bilirubin direk 3 mg/dl
Tuesday, July 12, 2011
Exercise

Bilirubin total 4 mg/dl

Bilirubin direk 0,9 mg/dl
Tuesday, July 12, 2011
Bayi 30 days old

Bilirubin total 21 mg/dl

bilirubin direk 1,5 mg/dl

other LFT’s normal

What do you think of the etiology?
Tuesday, July 12, 2011
Boy, 10 years

AST 65 IU/L

ALT 70 IU/L

What is your plan for the boy?
Tuesday, July 12, 2011
No
Tuesday, July 12, 2011
Please
No
Tuesday, July 12, 2011
Tuesday, July 12, 2011
The commonly used
liver function tests
may be abnormal
even in patients
with a healthy liver
Tuesday, July 12, 2011
Tuesday, July 12, 2011
Tuesday, July 12, 2011
Tuesday, July 12, 2011