Computer generated transcript

Warning!
The following transcript was generated automatically from the content and has not been checked or corrected manually.

Oh, on I reckon. Let's get started and and more people were drawing and I keep playing. And then here we go to start to storm for enough. Hi, guys. So I made one the co founders of the six PM Siris and Medical Crick in lead. We got a couple of other. The committee face members here is Well, you've got Lilly, whose was also part of committee in charge of the surgical surgical curriculum, Got partner who's medical vice leaders? Well, in a big part of committees, Well, and today we've got a doctor, Jack, who's going to be teaching on a lefty's jack diddly doo shirt off. I'm Jack. I'm just graduated from period. And I'm currently doing the F p at, um I'm here as well. Um, currently doing general surgery at hearing the hospital ice should be going to the next slide for the quick sponsors and stuff, and then we're going to. So if you were back, we keep going on about this. Please, please. If you have them done so already drawn on instagram Facebook and Twitter Page is how we keep people up to date. This'll last lecture of this Siris on then, if you want more information about going forward about what other sort of serious we're going to be doing, please follow up pages to keep up today. Go to next light, please. A Z you guys know was sponsored by the end. The you They were death since the beginning, and without them, we wouldn't have been able to get the six pm Siris off the ground. So when everybody graduates, they're gonna need some sort of medical medical legal advice at some point in their life, indemnity insurance and other sort of support. So if you want that you're interested in that, have a look at the end, the youth. There you are, codes in the bottom, right? And if you join thing, you also get a freebie. Such a revision cards or a some books to choose from his Well, we're not further ado. I mean, next slide. It's a lot of Jack. Oh, okay. Perfect. So, um, um, I'm going to give her like, let's atorium on the liver function test. The session will be targeted mainly for prick for the first year of clinical years, but it's also Africa before final years as well. And The approach is to give you some ideas as to how to interpret liver function tests and things about the differential diagnosis on the different clinical scenarios where you can get different patterns off liver function tests. And this is following the data. Inspiration. Siris, asshole. You have done other interpretation of other results on, but in clinical practice is you. When you put everything together and you get to a diagnosis so liver function test, it's only one piece of the clues. So most of the time, when you have clinical scenarios and exam questions, you often have other clues as well, like X rays. And we see Jesus Well, so I'm gonna give myself the story, which is the liver function test. I'm going to start off with the first question. Is there a pole function? Or I will put up the pool function for, you know, a little, um, so I'm going to read it if that if that helps. So you are asked to see a 78 year old male who has been admitted in intensive care for living at that nurses and treatment off septic shock. He requires a mission for way suppresses so I know Trump support for low BP. You're concerned about the liver function tests when it came back today on Do would hold the liver. Ultrasound is normal. Um, so this is the is that shown below? Um, so the bilirubin, The left album in A T and AARP E. If this doesn't make sense, we can go through them in a bit. Neutrophils and urea. So the neutrophil is that race? What's the underlying course off liver dysfunction? It's looking a gift. Um, another 30 seconds. And if you have any questions for you free to pop their in the chat, um, I think there will be at some points where the facilitators will pick up some questions and ask, um, if I don't know, I would direct you to some resources where you can find more information about it. So we got quiet. We got a half of the participants answering just great. Um, perfect. So, um, we've got the bones. Popular answer. Um, s d. And then the second most popular answer is he, um so that's going to the let's light. So the answer in this case is, um he lives Kenya. So going back to the question. It's sort of like a trick question. Basically, the only information that your total is that this elderly man has treatment of septic shock to where there is reduced tissue perfusion to move tissue on. In some cases, patients can have reduced blood supply to liver, and that causes liver scheme, which raises the lt by up to thousands, and we'll go through them later on. But the only three things that can make a nail ta go above 1000 s so you can have a scheme. Ear toxins, which is power, settle more or viral causes. And, um, and if you go back to the other options, so starting from the top. But Kyrie syndrome. So that is when there is a thrombosis off the Patrick vein. And there's no nothing that questions them saying about if the patient's procoagulant or in the history of clotting or coagulating disorders by the hepatitis is likely. But there's no further clues and the questions as to whether it could be happy or have your hep C. Um, some people put him pottery know syndrome, so keep Atorino syndrome occurs. Silent side with kidney dysfunction is when there is a kidney failure and that backs up onto the liver and causes liver failure as well. On, um, if you look at the previous previous, it's like although the urea is high, I don't know did not give any information about HFR. So you can start. Um, it's calculate that the patients has poor renal function or don't likely. So this is the learning from from this question is liver is chemo can cause massive transaminitis, which is race. I'm a a t in the scenario. Perfect. So two more questions. So this is the second question. Um, following from the first question, you may find it easier. So you are asked to review a 20 year old female which is probably by ambulance. She is known to the alcohol services. A past medical history includes emotion and stable person into disorder. On direct questioning, she denied taking any recreation substances. On examination, she is alert with a respiratory rate of 28 which is quite high, and the gas the VBG showed that metabolic acidosis, which means that the pH will be low and the bicarbonate will be low. So what is the most likely diagnosis? So here is the liver function test. Um, so we got quite a warming number off PE people going for certain options. So we mentioned about the Altes massively elevators. So there's only a few courses off that. Okay, I'm gonna stop here. Just do facilitate it quicker. So, um, so we have a young female with history off you PD, which means there are more, have a higher tendency to commit self harm and suicide. So So it is likely that the patient might have taken the past. That's what all of those, um although she denied taking any recreation substances. That's something that we can't really rely upon. Eso. The most likely answer would be passed over those and in your clinical years would be asked most often how to manage paracetamol with those. So, um, usually you treat with anesthesia or sustain, and you can look up the guidelines as to how often you give it for. So you give it a lot, of course, of 24 hours and the three separate dose on There's a separate criteria which are which is called King's chorus criteria for toxicity. And that is looking at your iron, which is your clotting time. And if that is very deranged, you will be eligible for liver transplant. So it's severe enough that requires a liver transplant. So you apply the King's college criteria to see whether the patient requires additional support. A liver transplant. Um, so that's the question case, too. Um, case three. Um, this is the final final question for this session. Um, you're asked to see a 80 old public library in with a three week history off each pill stools, dark urine and yellow sclera. He has two months history of weight loss. Um, included myocardial infarction on COPD. And he looks joined this on examination. Um, we have also requested the ultrasound, but I haven't been done. Um, and if you examine him, you can few. Um, the, um there's a mass in the right Upper Cordiant's, um, but it's not painful. Um, so, um, carba see a same positive. And these are the Bloods. So what's the most likely diagnosis? Redone? Is the post office actually, So I usually wait till the question I already realize. Okay. Perfect. Yeah. So put your boats in. Um, so those who don't know what causes the law is basically you have a probably in large right upper quadrant, so you share your brother. That's painless. Um, and we'll explain what that means, they told. I think most people go for C, which is a pancreatic cancer. So this is the most electric back. No cyst. So going through the other ones so cold. If I If I it's it's basically means course things. Presence, of course, things that can that is unlikely to course. The other symptoms, um, weight loss and also, um, it's an elderly gentleman. So it's more likely to have cancer and, conversely, assigned negative positive means that it's unlikely to course by Costin's basically so explain what that means. So in this case, if he had the ultrasound scans like likely, it showed there later, comin about duct and possibly a pancreatic mass. So what does the law say is days that a painless, probable in Large Corp ladder a company with a mild wrong? This is unlikely to be caused by your stents. So it's something that you know consultants right to ask in the war drown. But it's only it's usually not really testing exam. So the do you think that you take away from this question is in a patient with the obstructive picture. So if you look at the AARP is relatively high with, um, with reasonably Ruben on John, this, um, with a red flag, history is likely to be caused by obstruction. Typically a head of the pancreas compressing the common bile duct. You can have other causes, like common bile duct stone, but you wouldn't have the other history like weight loss and being set up. Okay, so this is just introduction to liver function tests. So my talk will be based around how to interpret liver function and liver enzymes. And you have any question just you free to take down below? Um, so I'm gonna go shoot into it. So liver is organ that has multiple function. And the reason being is that by knowing to function, you know, you know when things goes wrong, what what's your function will be malfunction. That makes sense. So it's starting from metabolism is metabolized, basically everything that you have, um, something from, you know, sugar Colaces, glycogen storage, glucose and desist. This what you learn in first year in terms of protein? It does, since it's in process a lot off coagulation factors and s O L B minutes. Well, albumin. And so it's a whole movement. Happen is, um, s so it is involved in, um, vitamin D hydroxylation. So from normal rhythm into 25 HYDROXYVITAMIN. D s. So that's part of the process. Where to Mindy becomes activated. They also mix. There are hormones that pepto hormones. There's a part of the liver function. In terms of drugs. It's most of the drugs were on the patch on the past. First pass metabolism by the pier for 50 enzyme system. So when the liver doesn't work properly, you need to think about stopping some drugs that can cause hepatic toxicity or reducing the dose. Because most of the drugs are bypassed, are metabolized by the liver in the first stage. And then miss importantly, I said I was involved in the synthesis off the bio on. But the function of bio is may sickly to help with the fat digestion and fat absorption and excretion of the fats, and also stories function as well, which I mentioned earlier. So this is a quick summary off the function of the liver and some some liver functions has, um, we can mainly sort of categorizes into the three main thing. So on the left you have the enzymes, and they're not really live enzyme in the sense that if you want to look at really look at how the liver is doing the best thing to look at, it's a synthetic function and how well the liver is actually making the protein. So you want to look at Elba, um, and the clotting factors. So if there's a severe acute drop in liver function, the things that we effect, it's actually albumin and clotting broader than the enzymes, the enzymes actually a picture off when deliver when and when the participants the liver cells are being attack or damage. That's when the liver enzymes will go up because the insects will be released from the hepatocyte it's on go for individual on Dzambasow, it's on, and in the middle we have bilirubin, which can be conjugated uncomplicated. And when I was going fruits of pricking colon in clinical early, I always find this so very confusing, so we'll spend some time going through the cycle bilirubin, and hopefully that makes sense when he comes to our interpretation the results. Okay, cool. So this is your standard lft panels. Usually it will include albumin protein lp lt else A S T. And the total bilirubin. So they don't have to break down off conjugating uncomplicated be Ruben. This usually give as a total bilirubin and the act, as I mentioned earlier, the actual function capacity of the liver is measured by Billy Rubin and l women and clotting factors. So how well the liver is doing the synthetic function is based on Elwin and the clotting factors. So plotting there's two types. So this I run on a PTT and I will show you a diagram to remind you what each of them mean and there most sensitive marker of liver damage. So if you have parasites of more patient power setting overdoes have acute injury to deliver, first thing would do is that the patient The clotting function will be deranged. So you have increased clotting because they're unable to produce a minor and the most of the clotting cascade proteins. Ah, have a half life off a few hours, so they're most sensitive. So on left inside, you can see could be what's in my mouth after. Okay, The on the left side you have the that interesting, interesting pathway, which is a long half way, and you measure by a PTT on On the right hand side, the intrinsic pathway, which is back to 75 and 10, is measured by PT prothrombin time. And then I know it's basically a normal ized to to measure, because different labs have different, um, since sensitivity and different, um, settings. So Arun eyes away to normalize everything, and I know one. It's no this this is, um, in the middle. And then anything above one means that the patient is more likely to bleed. S o r a z i n. I mean, the patients more likely to bleed, and there's less clotting factors around. And albumin is a negative acute face protein. So in the so, basically means that if someone is in the infection or inflammation states or high inflammatory state, the albumin will be low. So it's negatively correlated to infection inflammation. So going back to the liver and science we mentioned about few liver and since earlier, so they are Marcus off liver cell damage. So if there's inflammation off the liver cells, and liver cells die. The release enzymes. So the first one that people know about is a tea which is sensible, it Ellen Transferase and, um, as I lose it in the question stem for the first two questions. When you have transaminitis such a scheme, your virus and toxins bypass it a more the air to be raised up to 1000 so even more okay. And the normal range is around 30 to 50. So grace through 1000 means that it's very serious. And, um, it's when he participates, die release the enzyme and gives you a hepatic picture. Um, and going to ST so s e N L t are very similar. The thing is asked a R t. It's more specific. So yes, he is also found in other muscles. So skeletal muscle, heart, muscle and kidney issues. So if ST is specifically raised, there are also other reasons. So, for example, heart attack or kidney damage can also course of raising the ST um so in in separate depth with a pinch of salt when it comes to separating. S t a L T. There's one commonly known something that to note for you is that the ratio between ST and lt? So if the ST to a a T racial, it's more than 2 to 1. I think it says 2 to 0, but it's actually 2 to 1. Apologies one and 2 to 1. So if ST is doubled that lt, it suggests that the patients has more likely to have alcoholic hepatitis, so it's more likely to do to alcohol. Essentially, Um, so that's one thing. Um, if the A L t is more than the ST is likely to do two A chronic liver disease picture. So, for example, chronic hepatitis C advanced fibrosis. The van cirrhosis is you have a higher T A S T. There is an alcohol picture ST it's likely to be hired an lt Hopefully that makes sense. Okay, The next one is A L P um, which is alkaline phosphatase. And it is a group of enzymes found in, um, the sinusoidal tracks between the Paterson it's and the clinical remembrance between about ducks. So they're not. They're not essentially, he participates them or, like the cells around this deliver around the mattress. It's serving in the tracks and the membranes, and they're elevated if there is an obstruction. So typically when the about Doxil being damaged or there's obstruction off the flow off the normal bilirubin and that raises AARP pee, um, bear in mind that our peace also found in our gut issues as well. So mostly found in bone, small intestine and placenta. So so in a normal, erased, isolated race in AARP, pee could be many reasons, but you want to rule out other normal causes. For So, for example, pregnancy. In the third trimester, the AARP, you will be raised because percent of produces LP and in a pain in the elderly patient with the isolates and raised in AARP pee you want to think about Is the air be coming from the boat? So, for example, bone cancer or Paget's disease can cause the isolated race in a P. I brought primary burning to mess can honestly cause the race in AARP pee. Okay, but having said that, the more common causes of raising our peace do two obstructive picture. So a gallstone, for example, or a A a head of the pancreas cancer that blocks the flow off the bowel duct, and the last one is G T, which is gum. A little transferase again. It is found in Paterson. It's and is more so specific to chronic alcohol use. So if GTE is there a significant be an AARP is race you want to think about. Perhaps it's more like alcoholic alcohol picture. So it's found in chronic alcoholic access, if that makes sense. Okay, I will be going through this concept several times. So if you miss this, I will explain it again because this is very important. It's basically the bulk off the whole talk about liver enzymes anyway. All right, So we I mentioned earlier about what hepatic picture is, so is when the liver cells are damaged. Hepatocyte are being this insult student to the hepatocyte. It's so And when that happens, your own tea will rice a lot more than your air pee. So the coolest attic picture So hepatic picture was his colistat a picture So the common causes off insults to deliver have their many so alcohol a binge alcohol related liver disease. So a non alcoholic or nonalcoholic steatohepatitis So fat, for example, of patients very a beast that can cause inflammation of the liver steatosis viral hepatitis so hepatitis A B, C D E can course it's a hepatic picture, medications or toxin. So para settle more or commonly, some of the medication, like fibrates for patients taking for cholesterols can cause a race liver function. I'm test. They're very causes, and you will learn them throughout your clinical years so they're out immune. Cause is, there's, um, a tablet metabolite causes such as hemochromatosis when their spirit off iron. There's enzyme deficiencies and group buildup of copper and builds and disease. And there's other non hepatic causes that you should also consider. But it's unlikely to cause a massively raised hepatic picture. So a Z I mentioned if it's hepatitis or toxins or ischemia can cause a massively rays. Lt. Okay, moving on to Cholestatic picture is when your A L p. I think so. I pull against AARP. P G T. Is significantly higher than a A T and ST, so a L P is the one to look for. So if if you have a massively raise AARP, um, there's a blockage somewhere, and the way I would think about it is, think about where the blockage happens. Is it within the bowel duct or outside of the bowel duct, compressing into the bowel duct. So Intrahepatic cliff a cyst can be caused by drugs can also cause by primary biliary cirrhosis. Primary sclerosing cholangitis. These are conditions that affect the bio duct, either inflammation or stenosis on sclerosing off the duct, making it narrow. And unlike, make it harder for the about that to be drained and you have a tablet genetic conditions through. These are also some more. Recessive is where you have defective excretion off consecutively. Ruben in do being Johnson syndrome and Roses singer of this or quite rare, he wouldn't see them. It's more in the sink, so moving on to the extrahepatic causes more like it. You'll see them. So any strictures in about that? Technically, they're most more intrahepatic, actually, actually, that it could be good or stones in the common bile duct cancer, pancreatitis or tens of the gallbladder. These can cause cholestatic picture. So you have a race LP. Okay, so moving on, um, we mentioned earlier about Billy Rubin and talking about the cycle Billy Rubin. And this is where this is very important to go fruit and with you guys. So once you understand it makes much more sense. So going through the cycle off bilirubin, so festival you have, um, your him iron, which is in your red cell so that he, um I get broken down, um, into the hemoglobin, broken that into Billy Rubin. And the bilirubin is in the circulation. The blood is bound to albumin, which is the protein in the blood, and when it's bound to albumin is insoluble. So the first step, what will happen is that the bilirubin will go to a normal liver cell, which is the hepatocyte. And there when congregation happens. So congregation means that it will be attached to a asset sort into a conjugated Billy Rubin and once it's conjugated, is excreted into the bile. So the bio contains conjugated Billy Rubin and conjugated bilirubin is soluble, so it's actually sort of in the blood. And then, once that's secreted into the gut, the gut micro micro organisms bacteria will process them and we'll be converted into circle Bellingen, which causes thie your your stool to be have color. Brown color is the best where you have Circleville, Injun and in the blood. You'll be excreted by the kidney filters and excretes as durable in Asian. So this is how the cycle Billy Rubin works. And of course, some of them will be reabsorbed back to the hepatocyte and the cycle cursed same and see him again. So just a recap. You have the uncomplicated bilirubin, which the insoluble ones bound to albumin go into the liver and they'll be conjugated and secreted, fruity, common about food. He cystic duct going into the common bile duct going into the gut to, um, some of you guys may have heard off the different causes off base a bilirubin. So you know, people say, you know, the prehepatic causes hepatic causes that posthepatic causes. And, um, when you think about it, the resting to think about it, think about the cycles, the bilirubin. So where where does the damage happens? It is pretty cheap attic, meaning before bilirubin gets the liver, such as hemolysis. When there's Red Cell being broken down into him and he will be converse into uncontradicted. Be ruby in, you'll find it in your blood. They'll be a law uncomplicated. Billy Rubin. Worse is post hepatic, where there's obstruction going on. All of the bilirubin is being conjugated already and or leak into the blood. So right, and then going into the cards is getting leaks into the blood. So in your blood you'll find high conjugated bilirubin. So you have pre asthmatic and pasta Batic and hepatic just in the middle. And, um, can clearly we don't really measure that we can measure that we want to, but it's not routinely measured, but it's something that, you know, medical schools and SPS Question like to ask about just because it's quite technical and people you wish you get confused about it. But if you think about it, bilirubin goes in and conjugated goes to deliver it in. Conjugated on comes out. This is like a process. And, um, so living on. So I'm gonna give you a simple approach to interpret liver function tests. Um, so you have race Billy Rubin in your blood tests. Okay, if you look at your right hand side, if that's a race, L t s s t we mentioned that that means a insult to the hepatic science. So you want to think about a cube or chronic courses off habitate? And so, you know, viral causes is giving causes or two immune causes that causes the liver cells to die. You can also have race bilirubin because off cholestatic courses there blocked something being blocked. Okay, and either because it's there's a dilated docks. The common about that is being dilated, which means there's obstruction going on orders undulating so it could be other courses such as, um PP pp CMPs. See you can also for isolated the brace Billy Rubin. I guess it's only race bilirubin without any arrangement in the liver function test. So you have hemolysis. So, for example, when red cell being broken down for any reason where there's the autoimmune causes or infected infection causing the red cell to be broken down suddenly that will cause a massive we raised in bilirubin. But that itself will not affect the liver function test because that the disease itself is actually affecting the red cells, in a sense, and you better syndrome is something that you might come across the medical school. It's a genetic condition where there's a defective in three congregation process off the human off the bilirubin s. So you have less enzymes out there actually conjugating the Billy Rubin. So you have race Beirut. Uncomplicated bilirubin in that case usually happens when there's a stress stressful situation. So, for example, like alcohol binge or like infection, Patient to Cuba syndrome might have like a jaundiced. And when you met, do the blood work? There'll be a race with Ruben, but the liver functions hasn't been normal dexa in us in that scenario. So I've talked a lot about liver function tests, but in reality, just a lot of other stuff you can do. So it's not just blood work. You can do your ultrasound scan to look at the comment. The ducks you can look at the pathology is Gordon Levitt and score stones. Look at the pancreas as well, and you can also do a liver screen. So liver screen means that you look at how the liver is doing a PSA whole. I will. I'll give you go through some of the liver screen at the end. It's from. So this is why I briefly mentioned earlier, but just a different diagram and hopefully makes sense. So if you can see here, your Billy Rubin um, goes into the stool as Circleville, Indigent and some of them, the Urobilinogen will be absorbed back into the liver and and the whole cycle off Billy Rubin. Production continues, And once it's in the blood circulation, someone will be excreted as durable in urgent and it'll be excreted into the urine. Okay, so but the Ruben in the urine there shouldn't be any Billy Rubin. Okay, in the urine, this should have urobilinogen, but not actually Billy Rubin. So when you found Billy Rubin in the urine means that the the body itself can cope with actually, you know, converting into Europe indigent. So there may be a massive breakdown in red cells. You know, all of the red cells, him, him allies suddenly and then there's so much Billy Rubin and the body is so overloaded that the you and that comes up a spirit, Ruben. Okay, in terms of your ability, gyn, normally you would, detective, because this is part of the whole normal physiological process. It's when there's obstructive causes where you don't have Billy Rubin going into your You have been a gyn in your guts. Okay, then, that nothing comes into the gut and nothing goes into your blood circulation and comes out so you will find us absent and obstructive John. This and patient usually ask questions about you know whether you have post two or dark urine. This is this is very important, and obstructive joined this because if there's obstructive course, the conjugated bilirubin is not going into the gut. Has, that's know, stuck up in urgent And that course is a pair of stool, okay, and the same applies with dark urine. So there's no European religion pens they're stuck here in. So is that a way around? So I'm going to give a break to myself and everyone take a breather. And then we'll do some questions up the words on going through some other questions as well. Off that makes sense. And we can answer perhaps one or two questions. Yeah, I looked at the chapel. Okay, so someone mentioned about they last a graffiti. So, to be honest, throughout my medical school, I haven't really seen actually, someone do elastography. Another thing that people you should do is something called fibro scan, and so liver fibroscanned. So that is something that's quite commonly done. So it's basically about some proof and see how stiff the liver is. So a fibro scan measured um, live how to what extent deliver fibro's and, um, is usually magic in patients. We want to monitor their course of our example. Chronic liver disease, alcohol abuse or hepatitis. Some stuff. They're sick, really going to cirrhosis. So before they go into cirrhosis that the liver essentially five grows and stiff, and it gets different. So the fiber scan measures that and see how stiff the liver is. And but you're not really expected to interpret the results or going to know is that the scan exists. Um, if that makes sense Mm. Yeah, there's an typos. Apologies. Yes. So your ability gyn you're open it and going back is a, um your belly in urgent is a is a breakdown product off Billy Rubin. So when conjugated be rooting goes into the gut, the gap bacteria basically break down into your opinion. Urgent. And the you know, Bellingen is converted into circle Bellingen. Okay. Urobilinogen is absorbed into the blood system and excrete it into the kidneys. So going down. So you're see, um, positive. Um, you're a bit energon in a normal situation. Yes. Someone mentioned very well. So I'm conjugated Billy Rubin. So before they go in. There you go. You can't go into urine because they're insoluble to start with. Only conjugated to be the Reuben. It's tolerable. Okay, It it does take some time to get their head around it. But the important thing is that don't drop too much into the congregation. Uncomplicated. Because, as I said earlier, the important thing for this today is to figure out how to interpret liver function tests. And once you're good at that, and then you can look into the different Um um intrinsic Tito's off his Ruben. Okay, so I got for a couple of more questions for you guys to do on go through some of the answers afterwards. And, Jack, are we okay to give him about a minute to a minute? 30 seconds? Because I think they don't have enough time for the last question, if that's okay. Yeah, I got a question. So plenty of time to go through them. Perfect choke. So I will share it out. Yes, please. Okay. So you're also see a 24 year old male represents with normal liver function tests after a routine GP check. Um, he mentions that there's episodes of diarrhea in the last two years, and she's quite fatigue. He drink some alcohol hasn't been travel outside the UK, so it's not much detail, essentially, just a normal liver function tests. So what's the most lucky? That no sense. So the blood bilirubins raised the albumin is 40 which is normal. Lt is somehow raised. AARP is raise a bit more. An anti mitochondrial antibody is negative. And a, um, anti nuclear antibody is positive and we called quite good. Mixed responds. Okay, I think we have half participants. Um, answer me. Just get all right. So, um, Ms people go for see? So the answer is See? So explain why So let's go back to Let's go. Let's go of individual options first. So oh, to immune Hepatitis is usually, um, patients of autoimmune hepatitis usually have other manifestations. So there other indulgently disorders. So some of the questions they might mention about your thyroid disorders in the family they might have pernicious anemia. So when they have race B 12, um, when they have microcytic anemia and we have pernicious anemia, they're bitter, like I go on so other autoimmune manifestation and a and can be raised so this is quite computer is quite a I mean, technically, a could be correct, but more likely to be. See, um, going through the second one. So PBC PVC is usually found in women on usually in your forties. Andi PBC usually presents, um when there's race. Um uh, uh, cholesterol, fat and triglyceride. It's on the classic picture is some the middle aged women with liver failure, for example, and the usual presented itching, Um, first and D and eat of the is when this race 5 13, iron build up in the body and Wilson diseases when there's a race, um, copper as well. Okay, So going through PS psi, PSC's typically found in, um, patients with also collected. So if you have fasted client ist you are very likely. It's also called Develop PSC and eyes How it works. Is that cool or obstructive doing this because you're, um you're about duct Oscar Rose. And the pathology is when this Oscar rose and inflamed and you have high AARP and relatively lower lt because the actual disease process, the bio duct itself and the difficult thing that you see in your, um um suck using SPF is the bees on the shoe ring on us, And we typically nowadays, is usually that nose on MSN tree, which is the MRI off the pancreatic on the duodenum treat. So the biliary tree and patients with PSC has a high risk of developing cancer off the about ducks cholangiocarcinoma on it. It's quite poor prognosis. And so you ultimate treatment is liver transplants for these patients. So we have another question, um, which is a bit different. So you asked to see a 45 year old female who presents with for intractable it, um, lethargy, dry mouth. She also being hypothyroid for the last two years on examination, there was something last month. There is some stuff to join. This deliver is actually palpable. So there's a lot of Magalie what's the most likely diagnosis? Okay, so we got some questions. Some answers coming in. Do patients of UC get screened for PS psi? Yes. So they do get, you know, regular tracks with the patient. You see, they are under the care off the gastroenterologist, and every time they see, they always do LFTs. So, you know, usually it's allergies when it deranged you on the underlying course. Um, that's, um they don't get screening Acidic Lee by the old. This is one of the things complications they look for from Okay, so we could quiet. Quite majority going for a, um perfect. So I think this is a theocracy. It off the questions that you might see. So it's elderly, a mid middle aged female with drawn this. And, um and sometimes they also presents with other autoimmune disorders. So hypothyroid in the thousands business, this order the reason why it is no odor immune. Hepatitis is as as I said earlier, hepatitis is when you have inflammation of the liver, right, So you're a rt will be will be raised more than AARP e. Uh, that, Yeah. So in this case, in this question, the liver function test, it's more up. The AARP is raised more than lt. So it's more for obstructive cholestatic picture. And PVC is more likely this case. Okay, so you have, um when there is blockage off the blockage off the flow off the bio. Um, what happened is that your bio acids cannot sequester one of the fat and cholesterol in the blood stream, and so you have race, cholesterol raise triglyceride, it's and the keys instances because off the bio s, it's being released into the blood stream. Patients will get itching so typically will get itching first and PVC because of how the blurry trade just break down and release all off the bio assets. Um, and there's also association with the shoulder in, which is which is why I mentioned about dry eyes and dry mouth. They also associate with rheumatoid arthritis and hypothyroidism. And the enzymes that you want to look for in this case is the n a M anti mitochondrial antibody subtypes M two. So we call it, um A and to, um Is it the antibody to look for? And, um, And because of the fat metabolism being, you know, being, um, the range, um, you you end up having, um, the fat syllable approaching us fat soluble, fat soluble vitamins being affected. So you reduce clotting, reduce vitamin D and your patients With PBC, there's a higher risk of getting osteoporosis, um, on clotting disorder, because, um, these are the fat soluble proteins. They're being affected. Okay, as I mentioned briefly earlier about soft, non invasive liver screen so apart from the normal lft is the cashew team often ask for other test to look for the underlying course. It's a patient comes in, you know, they don't tell you what's going on They ever the range liver function and you want to find out what the underlying course So to do that they usually send off a n i l s o is the noninvasive that screen to look for the Latin going course. And you know, these are general clue off what could be included in the screen. So starting from biology, biology So hepatitis B and C looking better in mind that they look at different things. So hep b, they look at the surface antigen to see where they have been infected. So patient who is currently being infected the wall put Stewart will be positive surface antigen. Um, hep C will be anti help C antibodies in terms of human Tenex. So you can sort of Claritin for him. A chromatosis several placement for Wilson disease. So about chemistry. You can look for anti ships in for, um, alpha antitrypsin deficiency fasting, glucose triglyceride. So this is all be raised in PVC immune causes quite comments or two immune causes. So you want to look at a A, um, the globulins celiac also can cause a molly raised liver function tests on deliver ultrasound. So this is a summary, um, a quick summary of the different conditions. So in cirrhosis, if you can pop there in the chat or just write down in the piece of paper. So in cirrhosis, what do you expect? These four, um, test to change. So would you expect the SGLT to be high or low or normal? Clotting is a high, normal, low albumin and LP. I'll give you 15 seconds to think about just put, like a a row, like down, up, down. Okay, so cirrhosis is when there is liver failure to expect the synthetic function. We will be bad, so the liver is unable to produce clotting factors. So you I know the rates and nobody will be low regards to deliver sows itself. They can be normal, actually, because you know is a chronic process, so it's not stuck sudden insult to the liver and liver liver cells, so it can be normal. It will be raised if there's acute decompensation like acute in so you know where they have another bench and came in Very unwell. Then they might be raced. Okay, so next one will be acute liver failure. So, for example, a patient with parasites, Um, over those coming in liver failure. So what we expect the liver functions has to change. Okay, so we mentioned about acute insult, so your s t L t will be high. Yeah, Your clotting will be high as well, because if you liver is, um, unable to produce those Clozaril factors, okay? You're all women may be normal because albumin is actually a producing protein and it takes it takes time to do so that the half life, all women is around 20 days. So when you have acute insult, it takes time for the album into to go down. Um, and l women can be low for many reasons. We can talk about that a bit later. So in an LP, GTE maybe race or may not be raised, actually. Okay, So call the Stasis. So this is what we just get this one because we're using. So when there's a blockage, so a gallstone or head of pancreas cancer, you have race AARP Mawr than the ST. So your cholesterol picture will be raised on the right and alcohol abuse. You are expecting more GGT to be raised and depending of his chronic, all cute. So some this one will be for someone a Cubin, for example. You have a race, a t in this room. So an albumin can be low because off your liver not producing enough albumin, you can be low. Also, because there is, um, loss of protein because of kidney disease of nephrotic syndrome. Or it can be because of sepsis. When there's third. Spacing on, Delmon leaks out into the circulation into that, you know, in section to the foot space. So usually in this interstitial, for example, Okay, final stretch We're gonna go through with blasts through these questions. Um, hopefully will be easier, because I talk. So you asked to see a 21 year old male presented jealous, clever. He has returned from a sandwich or in some sense, his otherwise fits with no past medical history. He's not on any medication, is a known social bitch binge drinker. But also the night on the truck use was the most underlying course. Um, so this Erase the Ruben Normal liver function tests otherwise. So let's have a quick poll and see what we've got for here. Yeah, since I people go for the correct answer, Yes. No. Done. So this is a typical question. So you are have a race Bilirubin, Molly. Rates usually not crazily race, but your liver function test would be normal. So typically seen in patients with Cuba syndrome is when they have defective conjugation process. Okay, uh, trigly in the heart syndrome is when you have absolute deficiency in conjugation. So it's typically present in new names on day have connector. It's where there is race build off Billy Rubin in the brain, and they cause them to basically that die if they don't have a liver transplant. Absolutely efficiency. But you burn is relatively deficiency, and they, when you're fasting, stressed units that you should triggers it. Um, so there you go. If you are quite geeky like me, you want to learn about it. So basically, it's the enzyme deficiency. Call you tp transferase. That's for you to learn to sit home. But important thing is the clinical thing. So you bet syndrome. All right, then. Next question. You were asked to see a 38 year old African female who was admitted with joined this itch and dark urine a path. Medical history includes a fighter. I don't know, Memory Movil. So breast surgery, removal and recently treated you take five days ago. She drinks 21 units of alcohol per week. Smoke 15 a day from on examination. That's new substance of ascites. That's new about obstruction. Um, And if you do the blood work that's racing the Ruben my only raise L t s s t and raise L P. And not that race treated tea. So the way I would approach the question. So look at the individual component of the liver function test. Okay, So which one is the one most effective and think why? What is causing that? I think people are going to the right answer. But people, some, some some students are not participating. Gone, gone. I give you a couple of seconds more to pick the answers. Yeah, I need some participation. Nearly there. Um, there's two more, and I think they get harder and harder. I think this one is a bit harder, swell, but people seem to get Get beginning the right. Answer some, please. I'm okay. I think I would stop because we could. Quite a few. Okay, So the answer is he father for those that compare drug induce. So there's a clear trigger that she's been treated recently. Treated most likely. Antibiotic and antibiotic is one of the most common cause is off Drug induced called states that. So if you look at the questionnaire piece massively rates so is like it to be a place that picture likely to be secondary to a drug. Okay. And, um, the one that I have below is some of them common drugs, then course that cause of colors faces. So, um, antibiotics, for example, can cause cholestasis. It's like results. So if you stop them, you should come back. Um, so the typical ones to learn if I were you will be antibiotics or penicillin. Amoxicillin. Mac alights Easter gyn. So some, actually, some patients taking contraceptive pill can have that as well. Um, but it's not very common. All right, Next question. You raised food rest. Um, so you have a 18 year old. This is not really a liver function test question, but It's interesting. Anyway, so is 18 year old female you've seen recently. Came back from South America week ago, present a fever, diarrhea, joint and muscle pain and joint this and, um, she admitted taking some tablets in the neck up a tattoo and went for a cracking trip. She was fully vaccinated for the trip. And what's the most likely diagnosis? So to speed up your ancestor, I'm gonna go through your, um, the liver function test of you. So, grace bilirubin, normal albumin rays lt ST, um, also race LP. But you see more lt race morning. They'll pee because 400 and ST is not twice as highly air to see is actually high, but not as hard. Um, so you can see it's more of a hepatic picture. Okay, But conveniently, I give you all of the causes that causes liver derangement so I can see people are thinking, and it's quite spread, which is good. Here's a tricky one is no easy. Okay, um, give a little off. Um, what's called the law for, uh um, but herring. So you wouldn't get this in exam. It's more for learning purposes. All right. Okay. Those who pick D is correct. Okay, Why? So have a Texas A. Yes, you can have it and she can present with no severe diarrhea. But I did say that she was fully vaccinated, so it makes it unlikely. Have see a lot. People went for hep C. Yes, she had touch you down. And it's a common course off people getting hep C from, you know, unhygienic practices. But hep C takes time to develop, and it's too early is a one week ago, so it's unlikely to course severe derangement. And even if that's happened, um, it can. But it takes time for hep C to develop more like more likely patients present with joint and muscle pain and joint this so it's more fitting with electricity. Roose is, which is a bacteria commonly found when when people went for, like, a sports or things that involves water in the river. So, um, if you can see here So, for example, like soup age or sports of canoeing, you can get leptospirosis, which the bacteria and it can cause two between my algia. So this is a trick question. All right, last question. This is very hard, and there's forget it will be very good and we'll be finishing from back. And we'll do a couple of recap off the concepts and we'll be finishing policies with DeLay in little bit because we started a bit later. So a 75 year old man with the lumber back pain on the GPS done routine bloods and she found that the patient be the hemoglobin was was massively decrease from 2 33 uh, from 153 2. 33. Yes, those are fancy. There's no bleeding or any bad flex. However, when you examine him, um, she has pale his pale and he has a mouth on this and there's some lymph minutes found on the neck. Um, so what's the most likely supportive finding? So this is a two step question mean to figure out what's going on with this patient first. So you have a race. Billy Rubin. Low semen global. Um, normal liver function tests. They all TLP. It's normal. Um, a race MCB um, and reduce his be. The story is is this is the last one. You can also friend for help. If you don't know, this one is actually not really for 30. I mean, it's both for final year, but, um, there's no easy, so don't be discouraged if you get it wrong. So you I think that the important question is figure out what is the underlying course? So what What causes this first? Then you look at the oxygen option. So why the patient suddenly have a lotion, the globe in and race MCB. And they raised the Ruben I mention sometime earlier about a process that can court a process that can cause a race bilirubin of a massively dropped HB. All right. I think I think I'll give you. I'll stop in five seconds, if any more months to you boat, but majority necessary. Okay. All right. All right. Okay. So we got a majority option. People go for B. Oh, Okay. Anyway, so the answer is actually be on. We'll go for the options. Okay. So when someone presents with race and CV and isolates it race bilirubin, you want to think about what? The process. So the online processes humility, anemia when the red cells being broken down and you have seen and then race Billy Rubin. And you know when when you talk about humility. Anemia? This will be another talk. I can't squeeze everything in this toe. But essentially, um, think about what's the underlying course of humility. Anemia is the infective process of autoimmune process and in this case is more likely to be autoimmune. Multiple reasons. First reason being that she is old and Kiesle, IMF notes on, he has a weight loss, so it's likely to be see our also chronic lymphocytic leukemia. When that happens, you up more like it's produced a gym on antibodies against the red cells. So course autoimmune hemolytic anemia and that produces fair sites on the bloodstream. So going from the other options, so you have higher particular sites. So which of the young, immature red cells? So you have high red cells because a lot the rest has been damaged Heinz bodies and by cells. So these are G G six PD deficiency, So typically they would have, like a insult if they have some medication or some substances that causes the rest. Cells is certainly broken down. Um, absent you been a gyn is typically found in the cholestatic pictures obstructive picture, and the creams test is the test for the auto antibodies begin to the red cell. So there were positive in this case because it's a community military anemia today. Make sense. Yeah. So a quick summary. We talked about hepatic causes and call it static causes. And when cholestatic happened, you've raised AARP morning, You know, tea and hepatitic picture and they're raised other sources of race. A repeat PSA when it's race A repeat, don't think about just liver, think about other causes. And then we talk about three things that can cause a massively race. Lt. We also talked about other non specific courses, and ST can also happen when there's muscle damage, like heart muscles. In my training exercises, we also talked about prehepatic, posthepatic and prehepatic causes. And what a typical features and post hepatic, you know, the pills to end up you're in. And then when you talk about conjugated versus uncomplicated, you have the table here for you to take back a swell. We talk about the part mouse sorts being, um, circulation the whole process. But I'm not gonna go through again. And that's me. Um, so thank you very much for attending before you run away or really appreciate you just take a picture off. The right hand side is very quick. Feedback will be important for me to learn what can be improved. What do you like about a session? Um, is it too technical for you? It's your heart. Too easy on. I can incorporate that in my future session. And if there's anyone who have any questions about LFTs or in general medical school or F P trip application interviews, um, you know, if you free to drop me a message, um, if you're keen in, um when G um or you know, you want to do something, project wise or no, just reach out and we can see what we can do. Um, yeah. Thank you, Brennan. Thank you, Jack. Does anybody have posted a feedback link up in the chat as well? Please, please, jacks. Feedback. Like I said, we'll just teaching for free. It's It's how you sort of reward heroid the speakers for doing a good job on Kelly Jacks. Gonna done a good job and some things makes you to fill out a feedback. Please make sure to join our Facebook instagram on Twitter pages for more information. Remember, this is the last of this, Siris. But we will be back next month with a different Siris Will postmortem that on our normal pages, please follow us on the on. Doesn't have any questions for Jack in the chart or anybody. Doesn't matter. But the everyone's stunned. I think. Thank you for the questions that were being, um, clarify, which is very useful. Yeah. Thank you so much. Yeah, or good. Between me and a partner was all fight a part of Got to some of them before. I did get a complete that, like, every day when you got the nice this. Yeah. Yeah, it's always good. You always pick up your pick up new things from from other people from other people. So I don't know. The albumin had a half life of about 20 days. That's a useful town. Yeah. Yeah, exactly. I learned lots of examples. Actors, a little guys, pick ups, and usually albumin is useful in surgery as well. So if you see a patient underwent surgery, albumin will go down. And actually, when I get when they get better and recovering, you can actually look at the album and they actually get go up and up and up, so it's That's a good sign to see. Okay, you know, they might have infection going on, but the album is getting better, but it means that, you know, they're actually recovering from the operation and, you know, actually producing pro protein and actually having a good function. So this is one of the consultants told me the albumin is actually really good to see a general, well, health wellbeing of the whole patient. Yeah, exactly. Is, Jack said. Even the medicine we use is sort of how to see how crumbly a patient is. Prognostically wise happened How well I do. I had a patient with another man of 12, mostly related to severe cancer and neutropenic sepsis that they're so clearly they weren't going to do very well. They weren't going to do a snack, said. It's a very good sort of marker of how well the patient's going to do in hospital. Just nutrition wise and world, and, you know, obviously gonna have lots of edema and other things and other issues associated with it. And if they're pissing, uh, protein forever. But I believe that that I think there's no more questions for you upon, Uh, we will be posted according on metal. And again, I'll figure out about this idea verification thing that you guys have mentioned. But you can. Still a zombie should catch up content on the feedback. Make sure to do that when you feel on The feedback is a catch up content, but you'll get notified about when we post stuff issues still be able to access the slides and I'll work up. Everything is posted on metal Know guys on. But hopefully we'll have Jack back and future again for for another lecture at some point as well. Thank you very much. Like really appreciate. Good teacher. Cute. Thank you Upon are also being us. And then he's also here. Thanks, lady on. We'll see you guys next time. That's the end of this serious guys. So see you next month and thank you for joining us. And please spread the word. Well, people get better. We did. It just goes into