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lunes, 18 de julio de 2016

Elevated LFT: ED Management

emDocs - July 16, 2016 - Authors: Sulava E and Bergin S
Edited by: Koyfman A and Long B
"In today’s medical system, marginal laboratory values can lead to expensive, unnecessary, and potentially harmful further diagnostic evaluations. A 2012 retrospective, multi-center cohort study of patients presenting to the ED showed that laboratory testing has a direct effect on patients’ emergency department (ED) length of stay, with an average increase of 10 minutes for every five individual tests ordered. With routine incorporation of hepatic tests in blood chemical panels, it is crucial to have a detailed understanding of the pathophysiologic basis of liver function tests in order to establish appropriate clinical correlation and patient disposition.
Conclusions
LFT are commonly ordered laboratory tests with a variety of abnormalities in a vast array of disorders. By understanding the biochemical basis of each test, it is possible to correlate laboratory findings to a patient’s clinical presentation. By separating common hepatic disorders into subcategories based on the magnification of transaminase elevation, a more simplistic algorithm like approach can be taken to help narrow the spectrum of a differential diagnosis. This can be used to help eliminate waste in costly and unnecessary follow up studies by maximizing the understanding of what an LFT result represents.
  • LFTs = ‘hepatocellular’ or ‘cholestatic’ arrangement based on the pattern of elevation.
  • Hepatocellular pattern = transaminases > ALP
  • ALT is generally considered to be more specific to liver damage
  • Past medical history and social history are crucial insight to hepatic risk factors (table 3)
  • Magnitude of aminotransferase elevation => guide initial diagnosis: mild (<5x), moderate (5-10x), or marked elevation (>10x)
  • Mild = NAFLD, Drug Induced Liver Injury, Alcohol Induced Liver Injury
  • Moderate = Alcoholic Hepatitis, Biliary Tract Disease
  • Severe = Acute Viral Hepatitis, Ischemic Injury, Acetaminophen Toxicity
  • As always, supportive care is key in the ED!"