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MARCH 13, 2009
CLINICAL & LABORATORY APPROACH TO BLEEDING PATIENT
Sinus rhythm
Sinus rhythm= rhythm produced by electrical impulses formed within the SA node
P wave is always upright in leads I, II, aVF
Normal sinus rhythm rate 60-100/min
Sinus Rhythm
4 Questions to identify an ectopic rhythm
1. Are normal P waves present?
2. Are the QRS complexes narrow?
3. What is the relationship between the P wave and the QRS complexes?
4. The rhythm regular or irregular?
Ectopic impulse: premature beats
PAC
•Premature P wave
•Change morphology of P wave
•Usually narrow QRS
Ectopic impulse: premature beats
PJC Premature QRS
complex (usually narrow QRS)
Absent P wavePJC
Ectopic impulse: premature beats
PVCs
•Premature QRS complex
•No premature P wave
•Usually wide QRS complex with opposite T wave deflection
Ectopic impulse: Rapid ectopic rhythm Tachycardia group (rate~150-250/min)
Supraventricular tachycardia (SVT)Ventricular tachycardia (VT)
Flutter group (rate~250-350/min)Atrial flutterVentricular flutter
Fibrillation group (rate~350-450/min)Atrial fibrillation (AF)Ventricular fibrillation (VF)
Paroxysmal Supraventricular Tachycardia (PSVT)
Rate ~150-250/min, Regular rhythm
Abrupt onset & termination
Not seen sinus P wave (usually not seen P wave or retrograde P wave)
Usually narrow QRS complex
Paroxysmal Supraventricular Tachycardia (PSVT)
•Rate ~150-250/min, Regular rhythm
•Usually narrow QRS complex
•Abrupt onset & termination
•Not seen sinus P wave (usually not seen P wave or retrograde P wave)
Paroxysmal atrial tachycardia (PAT)
Regular Rate 150-250/min Warm up period Visible P wave (but
not sinus P wave)
Paroxysmal atrial tachycardia (PAT)
•Regular rhythm, rate ~150-250/min
•Narrow QRS complex
•Warm up period
•Visible P wave (but not sinus P wave)
PAT with block
Regular or irregular (if varying block) 2:1, 3:1, …
(2 P wave same morphology:1 QRS,
3 P wave same morphology:1 QRS)
PAT with 3:1 block
Multifocal Atrial Tachycardia (MAT)
Irregular rhythm ≥3 different P wave morphologies Rate >100/min (if rate
<100/min=Wandering pacemaker)
Ventricular Tachycardia (VT)
•Regular rhythm (may be slightly irregular)
•Rate ~150-250/min
•Wide QRS complex
Polymorphic VT
Like VT but QRS complexes different in morphology
Typical: QRS complexes spiral around the baseline, changing their axis and amplitude.
Polymorphic VT + prolong QT interval = Torsades de pointes
Atrial Flutter Regular or irregular
rhythm Atrial rate 250-
350/min Ventricular rate 1/2,
1/3, … of atrial rate “Saw tooth”
appearance AV block 2:1, 3:1,…
Atrial Flutter
•Regular or irregular rhythm
•Atrial rate 250-350/min
•Ventricular rate 1/2, 1/3, … of atrial rate
•“Saw tooth” appearance
•AV block 2:1, 3:1,…
Atrial Fibrillation (AF) Irregular rhythm Not seen P wave
(fibrillate baseline) Atrial rate ~350-
500/min Ventricular rate
variable
Atrial Fibrillation (AF)
•Irregular rhythm
•Not seen P wave (fibrillate baseline)
•Atrial rate ~350-500/min
•Ventricular rate variable
Ventricular Fibrillation
Multiple ventricular foci rapidly discharge producing a totally erratic ventricular rhythm without identifiable waves
Bradyarrhythmia
Sinus node dysfunction AV block
1st degree AV block
2nd degree AV block
3nd degree AV block
2nd degree AV block type I
2nd degree AV block 2:1
2nd degree AV block type II
Advanced 2nd degree AV block
Sinus arrest /pause
Sinus exit block
Sinus bradycardia
- Tachy brady syndrome
Sinus node dysfunction
Sinus bradycardia Sinus arrest /pause Sinus exit block Tachy-brady syndrome
tachyarrhythmia-atrial fibrillationbradyarrhythmia-sinus arrest
Sinus Bradycardia
Sinus bradycardia Sinus rhythm Rate<60/min
Sinus Arrest an d SA Exit Block
Tachy-brady syndrome
Escape Rhythms
Escape beats= rescuing beats originating outside the sinus node
AV Node (junctional rhythm): 40 to 60 beats/minute
Ventricles: 30 to 40 beats/minute
Junctional rhythm
Junctional rhythm
Rate 40-60/min Most often not seen P wave (Occasional
retrograde P wave) Narrow QRS complex
Idioventricular rhythm
Rate 30-40 /min Wide QRS complex
Accelerated Idioventricular rhythm
Rate 50-100/min Regular wide QRS complex
AV Block
First degree AV block Second degree AV block
Type I (Wenchkebach)Type II2:1 second degree AV blockAdvanced second degree AV block
Third degree AV block
1st DEGREE AV BLOCK
PR interval >0.2 sec All beats are conducted through to the ventricle
2nd DEGREE AV BLOCK: Mobitz type I (Wenckebach)
Progressive prolongation of the PR interval until a QRS is dropped
2nd DEGREE AV BLOCK: Mobitz type II
QRS complexes are dropped at regular intervals without prolongation of the PR interval
2nd DEGREE AV BLOCK 2:1
2 sinus P wave: 1 QRS complex Constant PR interval
(Impossible to tell whether it is Mobitz I or II)
High grade AV block (Advanced AV block)
≥ 3:1 AV blockConstant PR interval
Third degree AV block
No beats are conducted through to the ventricles.
AV dissociation: atrium and ventricles are driven by independent pacemakers
High grade AV block(constant PR interval)
3º degree AV block(AV dissociation)
Normal conduction
The Electrical Conduction System
Normal Bundle Branch Conduction
Ventricular depolarization Ventricular depolarization
V1 V6
Right Bundle Branch Block (RBBB)
Right Bundle Branch Block(RBBB)
Lead V1 M-shape QRS (RSR’)
Lead I, V6 Wide S wave
Left Bundle Branch Block (LBBB)
Left Bundle Branch Block (LBBB)
Lead V1 QS or rS
Lead I, V6 Monophasic R wave, no Q
RBBB, LBBB, IVCD
Secondary ST-T change
Left Anterior Fascicular Block
LAFB
1. Left axis deviation (usually>-60º)
2. Small Q in leads I & aVL, small R in II, III, aVF
3. Usually normal QRS duration
Left Posterior Fascicular Block
LPFB
1. Right axis deviation (usually> +120º)
2. Small R in leads I & aVL, small Q in II, III, aVF
3. Usually normal QRS duration
Axis change in fascicular block
Abnormal morphology
Abnormal P wave
LAE (P mitrale) RAE (P pulmonale) Abnormal P wave Axis
Abnormal P wave axis
Non-sinus P wave Arm lead reversal Dextrocardia
Abnormal P wave axis
Abnormal P axis : P wave is negative in I, II, aVF, positive in aVR
Origin of P wave is not SA node
In the same lead, there are two P wave morphology
This patient has atrial tachycardia
Arm lead reversal
Abnormal P wave axisQRS axis is also the same as P waveBoth P wave & QRS are normal in chest lead
Dextrocardia
Abnormal P wave axisQRS axis is also the same as P waveR wave regression in chest lead
Atrial enlargement
LAE RAE
PR interval
Short PR interval Prolongation of PR interval (AV block)
Preexcitation syndrome In the preexcitation
syndrome, there are accessory pathways by which the current can bypass the AV node and arrive at the ventricles ahead of time
Accessory
Pathway
WPW pattern
•Short PR interval
•Wide QRS complex with delta wave
•WPW syndrome= history of PSVT + WPW pattern ECG
Abnormal QRS complex
Abnormal Q wave Abnormal R wave Abnormal S wave
Normal ECG
Abnormal Q wave
Significant Q wave is 1 mm wide (0.04 sec in duration) or Q wave ≥1/3 of the QRS complex
Exclude lead aVR Significant Q wave = Infarction
Leads that may normally dis -play moderate to large size
d Q waves Lead III
Lead aVF
Lead aVL
Lead V1 (and sometimes also lead V2)
Lead aVR
Tall R in V1 Posterior wall MI Pre excitation Dextrocardia Duchene Muscular Dystrophy Right Bundle Branch Block Right Ventricular Hypertrophy Rotation of heart
Normal ECG
RVH
Dextrocardia
Abnormal P wave axisQRS axis is also the same as P waveR wave regression in chest lead
Isolated posterior wall MI
Pre excitation
Normal R wave progression
Causes of poor R progression LVH (left ventricular hypertrophy) RVH (right ventricular hypertrophy) Pulmonary disease (i.e., COPD, asthma) Anterior or anteroseptal infarction Conduction defects (I.e., LBBB, LAHB, IVCD) Cardiomyopathy Chest wall deformity Normal variant Lead misplacement
Poor R progression
ECG in COPD: Deep S in lead I, V5-6
ST segment deviations
J point elevation
Common causes of ST segment depression
1. Ischemia2. “Strain”3. Digitalis effect4. Hypokalemia / Hypomagnesem
ia5. Rate-related changes6. Any combination of the above
Various type of ST segment depression
ST elevation Acute myocardial injury Myocardial aneurysm Pericarditis Early repolarization pattern Myocarditis Repolarization abnormality
chanellopathy : Brugada syndromeelectrolyte abnormalitydrugs
Severe chest pain in a 45 yoman
Acute IWMI with ST depression V
1-V3
Myocardial injury
Early repolarization
LBBB with STT changes
Acute pericarditis
Evolution of acute pericarditis
ST segment elevations
Convex=MIConcave=pericarditis
T wave morphology
Inverted T abnormality Cardiac ischemia /injury Cardiomyopathy Brain pathology Repolarization abnormality
secondary repolarizationchanellopathy : LQTSelectrolyte abnormalitydrugs
Leads that may normally dis play
T wave inversion Lead III
Lead aVF
Lead aVL
Lead V1 (and sometimes also lead V2)
Lead aVR
- Causes of nonspecific ST T changes
Ischemia LVH Cardiomyopathy Mitral valve prolapse Drug effect (digitalis, antiarr
hythmic agents) Electrolyte disorder (i.e.,hyp
okalemia, hypomagnesemia)
CNS disorder (stroke, intracerebral bleed,etc.)
Hyperventilation Severe medical illness Severe emotional stress Exercise Hypoxemia Acidosis Temporature extremes (h
ypothermia,hyperthermia) Many others...
Hyperkalemia
Tall peak T: HyperK
Hyper K
Hyper K: Tall T, wide QRS, bradycardia
QT prolongation
Common causes of QT prolongation1. Drugs
○ Type I A & Type III antiarrhythmic agents ○ Tricyclic antidepressants○ Phenothiazines
2. “Lytes”○ Hypokalemia○ Hypomagnesemia○ Hypocalcemia
3. CNS○ Stroke○ Intracerebral or brainstem bleeding○ Seizure○ Coma
Hypokalemia
ECG in ischemic heart disease Q wave= infarction ST elevation= acute injury (transmural) ST depression= acute injury
(subendocardial) Inverted T wave =Ischemia
Consider for other Differential diagnosis
AMIAcute Myocardial Infarction (AMI)
ST elevated MI
ECG:ST elevation
Non ST elevated MI
ECG:ST depression or
Inverted T or
Normal ECG
Q wave MI Non Q MI
Q wave MI Non Q MI
Basic Lead Groups
Inferior leads - II, III, aVF
Septal leads - V1, V2
Anterior leads - V1 to V4
Lateral leads:
Lateral precordial leads - V4 toV6
high lateral leads - I, aVL
Basic Lead Groups
Coronary anatomy
ECG in AMI
Dating infarctionAcute infarction - onset within hours up to
a day ST segment elevation is hyperacute or c
oved, and often marked Q waves are small or absent T wave inversion is minimal or absent Reiprocal ST segment depression is ofte
n present, and may be marked.
Dating infarctionRecent (or “subacute”) infarction - onset within a day or
so, up to several days to a week. Q waves are often present; they may be small or large. ST segment elevation is minimal or absent. T wave inversion is often present and may be marked. Reciprocal ST segment depression is minimal or absent
.
Dating infarction
Old infarction - onset over a week ago Q waves are present and are often large. ST segment elevation is absent. T wave inversion is minimal or absent. There is no reciprocal ST segment depres
sion.
Acute MI (Anterior wall)
ST elevation:Acute inferior wall MI
Old inferior wall MI
Summary
Data gathering1. Rate
2. Rhythm
3. Axis
4. Interval
5. Chamber enlargement
6. Morphology
SummaryAbnormalities Rate & rhythm (Arrhythmia)
TachyarrhythmiaBradyarrhythmia
MorphologyP waveQRS complexST segmentT waveInterval: PR, QRS, QT
Further reading
The Only EKG Book you’ll ever need. Malcolm S. Thaler. Fourth edition.
Rapid Interpretation of EKG’s. Dale Dubin.
Marriott’s Practical electrocardiography Galen S. Wagner.
ECG ทางคลิ�นิ�ก : ยงย�ทธ สหั�สก�ลิ
Total circulating level of thyroid hormone
Total circulating level of free hormone
Dynamic test of thyroid functionTests of peripheral tissue functionTests of hypothalamic-pituitary
function
Serum TT4Serum TT3
Total circulating level of thyroid hormone
Total circulating level of free hormone
Dynamic test of thyroid functionTests of peripheral tissue functionTests of hypothalamic-pituitary
function
- Direct methods: FT4, FT3
- Indirect methods: Calculated free thyroxine index
Total circulating level of thyroid hormone
Total circulating level of free hormone
Dynamic test of thyroid functionTests of peripheral tissue functionTests of hypothalamic-pituitary
function
Thyroidal radioisotope uptakeT3 suppression test
Total circulating level of thyroid hormone
Total circulating level of free hormone
Dynamic test of thyroid functionTests of peripheral tissue functionTests of hypothalamic-pituitary
function
Ankle tendon reflex durationSerum lipid levelsEKG
Total circulating level of thyroid hormone
Total circulating level of free hormone
Dynamic test of thyroid functionTests of peripheral tissue functionTests of hypothalamic-pituitary
function
TSH (Thyrotropin)TRH (Thyrotropin releasing
hormone )test
4Thyroxine (T ) circulates ~999.7% bbbbb bb bbb bbbbbb bbbbbbbb
- - 6075TBG ( %);- - / (1 5 3 0 %)- ( 1 0 %);
[ Thyroxine Binding globulin (TBG), Transthyretin (TTR)/Prealbumin (TBPA)]
T 3riiodothyronine (T ) is ~ 99.7% bbbb d, pr i mar i l y t o TBG
TT4 and TT3 circulate at nanomola r concentrations,
bbb bbb bbbbbbbb bb bbb bbbbbbbb4 3b bbbbb
- The i nt er met hod var i abi l i t y f or tbbbb bbbbbbb bbbbbbbbbbbb
TT4 -1017% andTT3 -20 30%,
I t is believed that the minute free fraction o f hormone is responsible for the biologic ac
tivity of thyroid hormones at the cellular le vel
0024. %FT 02 3. % FT
( Robbins J. 1996. Thyroid hormone transport proteins and the p hysiology of hormone binding. In: Gray CH, James VHT, eds. Hor
-mones in Blood. London: Academic Press. 96 110.)
Sbbbbb bbbbbbbbbb bbb bbbbbb bbbbbbb (TBGexcess or defi ci ency)
Familial Dysalbuminemic Hyperthyro xinemia, FDH
T4 and T3 autoantibodies Ibbbbbbbbbb bbbbbbbbbb bbbb bb bbbb
matoid Factor and Heterophilic antibo dies(HAMA)
Salicylate, FurosemideHeparinAmiodarone, Iopanoic acid,
Propanolol > 160 mg/dAmphetamineHeroin, Methadone
Phenytoin, Phenobarbital, Carbamazepine
Dopamine (FT4 อาจปกติ�ก�ได้�)Lithium
GlucocorticoidDopamine
Hyperestrogenic stateDrugDiseaseGenetic
Hyperestrogenic state
PregnancyEstrogen therapyNew bornOral contraceptive pillsEstrogen producing tumor
DrugHeroinMethadonePerphenazine
Disease
Acute intermittent porphyriaAcute viral hepatitisChronic active liver diseaseAIDSOat cell carcinoma
Genetic
X-linked familial increase in serum TBG
Exogenous androgensMajor illnessDrugDiseaseGenetic
Drug
CorticosteroidsDrugs displacing thyroxine binding sites
- Salicylate- Diphenylhydantoin- Furosemide
Disease
Cushing’s syndromeSevere (Cirrhotic) liver diseasesActive acromegalyNephrotic syndromeProtein-losing enteropathies
Genetic
Familial X-linked deficiency of TBG
SerumTgmeasur ement i s used as a t umor mabbbb bb bbb b bbbbbb bbb bb bbbbbbbb b
ith differentiated thyroid carcinomas (DTC)
bbbbbbb bb b bbbbbb bbb bbbbb bbbbbb on IMA or RIA techniques
- Ther e i s a t r end f or non i sot opi c Ibb bbbbbbb bb bbbbbbb bbb bbbbbbb
Ma ssofdifferentiatedt hyr oi d t i ssue pr esent (nor ma l tissue + tumor)
A ny inflammation of, or injury to thyr oid tissue, such as follows fine needle
aspiration biopsy, surgery, radioiodin e t her apy or t hyr oi di t i s
b egree of stimulation of TSH receptor s (by TSH, hCG or TSAb)
(DTC= differentiated thyroid carcinoma)
TSH
Tg
A- ntithyroidperoxidase(TPO), thyroglobulin(Tg) and TSHr ecept or s ar e use d i n t he di agnosi s of aut oi mmune t
bbbbbb bbbbbbbbb
Thyroid Autoantibody Prevalences and Associations with Hypothyroidism
A ntibody measurement techniques h - ave evolved from semi quantitative a
gglutination and complement fixation tests and whole animal bioassays to s
pecific ligand assays using recombina nt antigens and cell culture systems t
ransfected with the human TSH recepbbb
TRAb (TSAb & TBII)(TRAb= Thyrotropin receptor Ab; TSAb= Thyroid stimulating Ab; TBII = Thyrotropin binding inhibitory Ig)
Thyroglobulin autoantibody (TgAb) in terference with serum Tg measureme
nts remains the most serious problem limiting the clinical value of serum Tg
bbbbbbbbbbb. Serial TgAb measurements can be us
ed as an independent prognostic test - for the presence of Tg secreting thyro
bb bbbbbb
- - Comparisons of TgAb negative and TgAb Positive Subjects
TRAb tests are used in the differential diagnosis of hyperthyroidism, the pre
diction of fetal and neonatal thyroid d ysfunction due to transplacental pass
age of maternal TRAb and prediction the course of Graves' disease treated with antithyroid drugs
( Michelangeli V, Poon C, taft J, Newnham H, Topliss D, and Colm an P. 1 9 9 8 . The prognostic value of thyrotropin receptor an
tibody measurement in the early stages of treatment of Graves' -disease with antithyroid drugs. Thyroid. 8:119 24.)
TherelationshipbetweenserumTSHandfreeT4concentrationisshownfornormalsubjects(N) and i n t he t ypi cal abnor mal i t i es of t hyr oi d f unct i on: A, - primary hypothyroidism ; B, central or pituitary dependent hypothyroidis
m; C, thyrotoxicosis due to autonomy or abnormal stimulation of the glan - d; D, TSH dependent thyrotoxicosis or thyroid hormone resistance. Note t
hat linear changes in the concentration of T4 correspond to logarithmic c hanges in serum TSH.
An algorithm for the initial assessment of thyroid fun ction, based on initial assay of serum TSH. This
strategy also has some limitations.
TSH Reference Ranges
Measurement of serum T4 , rather than serum TSH, is the more. r eliable single test of thyroid function when steady state condition
s do not apply, as in the early phase of treatment for thyrotoxicosi s or hypot hyr oi di sm.
This assay does not have a general diag nostic role, despite previous suggestion
s that it might be useful in distinguishin g true hypothyroidism from the hypothy
roxinemia of severe illness.
( Burmeister LA, Reverse T3 does not reliabl y differentiate hypothyroid sick syndrome f
rom euthyroid sick syndrome. Thyroid 199 -5 5 43541; : .)
- Grave's Disease- Toxic nodular Goiter- Toxic Thyroid Adenoma
- Acute viral thyroiditis- Silent thyroiditis- Struma ovarii- Excessive Levothyroxine ingestion
การส�งติรวจ Thyroid function tests จะส�งเมื่ !อมื่"ข้�อบ่�งชี้"&ทางคลิ�นิ�ก
การเลิ อกชี้นิ�ด้ข้องการติรวจใหั�เหัมื่าะสมื่ จะเป(นิประโยชี้นิ*แลิะประหัย�ด้ค�าใชี้�จ�าย
การติรวจ TSH เพี"ยงติ�วเด้"ยว สามื่ารถใชี้�เป(นิการติรวจค�ด้กรองข้�&นิแรกว�าผู้/�ป0วยมื่"ความื่ผู้�ด้ปกติ�ในิการท1างานิข้องติ�อมื่ธ�ยรอยด้*หัร อไมื่�
ในิผู้/�ท"!มื่"การเจ�บ่ป0วยร�นิแรงแลิะสงส�ยภาวะ Hypothyroidism ใหั�ติรวจ TFT ท�&ง FT4, FT3 แลิะ TSH
Approach to Patients with Abnormal LFTs
And Viral Markers
• Misnomer, not effectively assess the
actual function of liver• Liver chemistry tests = biochemical
tests for hepatic injury, cholestasis,
hepatic synthesis• Normal values do not mean “normal” eg. normal
ALT is Mean+ 2 SD and was set as early as 1950s
Advantages Non invasive method of
screening liver dysfunction
Pattern of laboratory test abnormalities to recognize the type of liver disorder
Assess the severity of liver dysfunction
Follow the cause of liver disease
Disadvantage Lack sensitivity: normal
results in serious liver disease
Not specific for liver dysfunction
Seldom lead to a specific diagnosis
Chemistry Implication
ALT/AST Hepatocellular damage
Bilirubin Cholestasis, impair conjugation, biliary
obstruction
ALP Cholestasis, infiltration, obstruction
GGT Cholestasis, obstruction
5’-nucleotidase Cholestasis, obstruction
Albumin Synthetic function
PT Synthetic function
Albumin Coagulation
factors
Aminotransferases• Bilirubin• Alkaline
phosphat-ase
• GGT
Test of the biosynthetic capacity of the liver
Liver synthesize factors I, II, V, VII, IX and X PT prolong : single or combination factors
deficiency Advantage of using PT more than INR Indicate severity and prognosis of liver disease
PT prolong not specific for liver disease Consumptive coagulopathy, vitamin K deficiency and
ingestion of drugs Factor V is synthesized by liver but not affected
by vitamin K deficiency Vitamin K deficiency : PT improve at least 30%
after vitamin K injection 10 mg within 24 hrs
Synthesized exclusively by the liver,Half life 19 - 21 days Serum level reflects the rate of synthesis,degradation and volume of distribution
HypoalbuminemiaDecreased synthesis:
-Severe liver damage or chronic liver disease-Chronic inflammation-Protein malnutrition
Losing albumin: -Protein losing enteropathy
-Nephrotic syndrome
Serum immunoglobulins are produced by stimulated B lymphocyte
Elevation of serum globulin level:• Chronic liver disease:
- Indicate impaired function of RE cells in hepatic sinusoids- Shunting of portal venous blood
• Chronic inflammatory and malignant diseases
*Triger DR,et al,Lancet,1973
Reverse A/G ratio Cronic liver disease or cirrhosis Chronic inflammation or infection
Hypoalbuminemia ,hypoglobulinemia, anemia and decrease cholesterol level Malnutrition
Hypoalbuminemia ,hypoglobulinemia and increase cholesterol level Protein losing enteropathy Nephrotic syndrome
Aminotransferases
• Bilirubin• Alkaline
phosphatase• GGT
Test to detect injury to hepatocytes
•Albumin•Coagulation factors
AST or SGOT• Cytoplasmic and
Mitochrondial form
• The half-life• Total AST ~ 17
hrs • Mitochondrial
AST ~87 hrs
ALT or SGPT• Cytoplasmic
forms• The half-life is
47+10 hrs
Hepatic EnzymesHepatic Enzymes
Ischemia
Immune reaction
(AIH,PBC,PSC)
Infection (virus, bacteria)
Medications
Toxin / Alcohol
Endogenous Exogenous
Hepatocyte
AminotransferaAminotransferasese
Copper/Iron overload
(Wilson’s disease/Hemochromatosis)
Most types of liver disease : ALT>AST activity
AST come from non hepatic tissue: heart ,skeletal tissue and red blood cell
ALT is low concentrations in tissue other than liver Specific for hepatocellular injury Non hepatic conditions etc myopathic disease1-2 and
kidney
1 Scola RH, et al. Arg Neurosiquiatr 20002 Lin YC, et al. Taiwan Erch Ko I Hsueh Hut Tsa Chili 1999
Test Normal Mild Moderate Marked
AST 11 – 40 <2 -3 2 - 3 to 20 >20
ALT 3 - 40 <2 -3 2 - 3 to 20 >20
ALP 35 – 105 <1.5 -2 1.5 - 2 to 5 >5
GGT 2 – 65 <2 -3 2 - 3 to 10 >10
Factor AST ALT
Time of day 45% variation during day; highest in afternoon, lowest at night
Day to day 5-10% variation from one day to next 10-30% variation from one day to next
Race/gender 15% higher in African-American men
Body mass index (BMI)
40-50% higher with high BMI 40-50% higher with high BMI
Meals No effect No effect
Exercise 3-fold increase with strenuous exercise 20% lower in those who exercise at usual levels than in those who do not exercise or exercise more strenuously than usual
Specimen storage
Stable at room temp for 3 d, in refrigerator for 3 wks (<10% decrease); stable for years frozen (10-15% decrease)
Stable at room temp for 3 d, in refrigerator for 3 wks (10-15% decrease). Marked decrease with freezing/thawing
Hemolysis, hemolytic anemia
Significant increase Moderate increase
Muscle injury Significant increase Moderate increase
Other Macroenzymes Macroenzymes
Useful in narrowing the DDX for cause of the liver injury1) Level of aminotransferase elevation
2) Predominant AST elevation
3) Rate of aminotransferase declination
1. Level of aminotransferase elevation Acute hepatic injury
Hepatocyte damage occurs abruptly and over a short period of time
Aminotransferase elevation : > 8 – 10 times UNL Chronic hepatic injury
Hepatocyte damage occurs chronicity more than 6 months
Aminotransferase elevation : < 5 times UNL
Acute viral hepatitis (rarely >2000-3000 IU/L)
Ischemic liver Toxic and drugs:
Paracetamol, halothane Acute Budd-Chiari Syndrome Hepatic infarct or artery ligation
Chronic Hepatitis B and C Alcohol Medication,Toxin Nonalcoholic Fatty liver Disease Autoimmune Hepatitis Wilson disease Hemochromatosis
Disease Peak ALT (x URL)
AST / ALT Ratio
Peak Bili (mg/dL)
PT Prolong (s)
Viral Hepatitis
10-40 <1 <15 <3
Alcoholic Hepatitis
2-8 >2 <5 1-3
Toxic injury
>40 > 1 early <5 >5(transient)
Ischemic injury
>40 >1 early <5 >5 (transient)
X- times, URL - upper reference limit
2. Predominant AST elevation Alcoholic liver disease Extrahepatic source of AST:
Hemolysis Skeletal muscle disease Cardiac muscle
Cirrhosis
AST > ALT activity Alcohol induces release of mitochondrial AST
from cells without visible cell damage 1
Pyridoxine deficiency decreases hepatic ALT activity 2
1 Zhov S-L, et al. Hepatology 19982 Luding S, et al. Gastroenterlogy 1980
3. Rate of aminotransferase declination Rapid declination of aminotransferase
Ischemic hepatic injury Drug induced hepatitis : short half life drug Acute biliary tract obstruction Fulminant hepatitis
Slow declination of aminotransferase Acute viral hepatitis Drug induced hepatitis : long half life drug Autoimmune disease,Metabolic disease
0
2000
4000
6000
8000
10000
1 2 3 4 5 6 7 8 9 10
AST
LDH
Days
U/L
Giltin N,et al ,Am J Gastroenterol,1992
The patients had a rapid striking elevation of AST and LDH, with rapid resolution
History of drugs, alcohol, co morbid conditions,family history and PE
HBsAg Anti-HCVconsider- -
NASH (DM, obese: ALT>AST)Wilson(neuro, family: ceruloplasmin)Autoimmune(female:ANA, SAM)Hemochromatosis(Fe, ferritin, TIBC)
elevated > 6 months without cause
Biopsy
HCV-RNAHBeAg, DNA
Albumin Blood-clothing
factors
Aminotransferases• Bilirubin• Alkaline
phosphatase
• GGT
Test of the capacity of the liver to transport organic anions and metabolize drugs
Heme
Biliverdin IX
Unconjugated bilirubin IX
Lipid-soluble,
Normally in plasma
Conjugated bilirubin Conjugated bilirubin IXIX
Water-solubleWater-soluble
Normally in bileNormally in bile
Heme Oxygenase
Biliverdin reductase
NADPH
Bilirubin UGT
Alkaline Phosphatase(ALP)
0
1
2
3
4
5
6
Age
Female
Male
Up
per
refe
ren
ce lim
it(r
ela
tive t
o 2
5-3
5 y
rs,
Male
s)
0 10 20 40 60 80
Age and Gender effects on URL for ALP:The URL for 25-35 year old male is set at 1.0.ALP is many fold higher in children and adolescents,reaching adult activities by about age 25.
Factor Change Comments
Day to day 5-10% Similar in liver disease and health, and in elderly and young
Food ingestion Increases as much as 30 U/L In blood groups B and O; remains elevated up to 12 hours; due to intestinal isoenzyme
Body mass index (BMI)
25% higher with increased BMI
Exercise No significant effect
Hemolysis Hemoglobin inhibits enzyme activity
Pregnancy Increases up to 2-3 fold in third trimester
Due to placental and bone isoenzymes
Smoking 10% higher
Oral contraceptives 20% lower
Specimen storage Stable for up to 7 d in refrigerator, months in freezer
A membrane bound enzyme Decreasing order : proximal renal tubule, liver,
pancreas and intestine GGT activity in serum comes primarily from liver The half-life :
7-10 days in humans 28 days in alcohol-associated liver injury
Increased GGT : diabetes, hyperthyroidism, rheumatoid arthritis, COPD,
acute myocardial infarction*
Age-and gender related differences
*Hedworth-Whitty RB,et al,Brit Heart J,1967
Mild elevation ALP
Repeat to confirmHistory and PE
Hepatic image
Normal Confirmcheck GGT
GGTcontinue
GGT normalbone
Drug or alcoholrepeat 2-8 wksafter withdrawal
Specific diseasework up accordingly
NASH
Dilated duct
ERCP
Normal
Parenchymal disease
Infiltrative lesion • TBc, fungal, other granulomatous, malignancy• PBC
Liver mass (s) Partial biliary tract obstruction (Stone, PSC) Drugs – Anti - convulsants, Warfarin