Laboratory Work-up

Unica Francisco

LABORATORY WORK-UP

History (focus on medication/ drug exposure)Physical Examination

Lab tests: Bilirubin with fractionation,ALT, AST, alkaline phosphatase, prothrombin time and albumin

Isolated elevation of the bilirubin

Bilirubin and other liver tests elevated

Algorithm for patients with jaundice

8.16.11 Reference

Direct Bilirubin 223.7 3.4-13.0

Indirect Bilirubin 95.7 0-18

Total Bilirubin 319.4 8.5-23.6

SGPT/ALT 201.90 0-45

SGOT/AST 220.20 0-35

ALP 507.48 30-120

Isolated elevation of the bilirubin

Indirect hyperbilirubinemia

(direct < 15%)

Drugs(rifampicin, probenecid)

Inherited disorders

Gilbert's syndrome Crigler Najjar

Hemolytic disorders

(Ineffective erythropoiesis)

Direct hyperbilirubinemia(direct >15%)

Inherited disorders

Dubin-Johnson syndrome

Rotor's syndrome

Bilirubin and other liver tests elevated

Hepatocellular pattern:ALT/AST elevated out of proportion to alkaline

phosphatase

1. Viral serologiesHepatitis A IgM

Hepatitis B surface antigen and core antibody (IgM)Hepatitis C RNA

2. Toxicology screenAcetaminophen level

3. Ceruloplasmin (if patient less than 40 years of age)

4. ANA, SMA, LKM, SPEP

Cholestatic pattern Alkaline phosphatase out of proportion

ALT/AST

Ultrasound

Dilated ducts Extrahepatic cholestasis

CT/ERCP

Ducts not dilated Intrahepatic cholestasis

Serologic testing: AMA, Hepatitis serologies, Hepatitis A, CMV, EBV

Review drugs

8.16.11 Reference

SGPT/ALT 201.90 0-45

SGOT/AST 220.20 0-35

ALP 507.48 30-120

IMAGING STUDIES RESULTS

ABDOMINAL ULTRASOUND Normal sized liver with mild fatty changesIll defined hypoechoic structure at the region of the peripancreatic head with secondary dilation of the intra and extrahepatic and pancreatic ducts. These findings are worrisome for periampullary growth.CT/ERCP was recommended for confirmation

Ultrasound Findings

Pancreatic head Intrahepatic duct dilatation

Dilated pancreatic duct Extrahepatic duct dilatation

TUMOR MARKERS

CA 19-9

• CA 19-9 antigen is a sialylated oligosaccharide that is most commonly found on circulating mucins in cancer patients. It can be elevated in acute or chronic biliary disease.

• Patients with pancreatic carcinoma, 75-85% have elevated CA 19-9 levels. CA 19-9 value of greater than 100 U/mL is highly specific for malignancy, usually pancreatic.

CEA

• Carcinoembryonic antigen (CEA) is a high–molecular weight glycoprotein found normally in fetal tissues. It has commonly been used as a tumor marker in other gastrointestinal malignancies.

• The reference range is less than or equal to 2.5 mg/mL.

• Only 40-45% of patients with pancreatic carcinoma have elevated CEA levels.