License and Zenith

Loksewa at
Zenith
015424901, Zenith
9808222095
ZENITH
015424901,
9808222095
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Enzyme
Range vary according to Kit or Method. So Clinical based Question should have given standard normal
range for interpretation
Enzyme Normal range Enzyme Normal range
ALT  Adults: 7 to 56 U/L (units per liter) AST  Adults: 10 to 40 U/L (units per
(Alanine Aminotransferase)  Children: 10 to 60 U/L (units per liter) (Aspartate Aminotransferase) liter)
or or  Children: range of 20 to 80
Serum Glutamate-Pyruvate  Increase in Infective hepatitis Serum Glutamate-Oxaloacetate U/L.
Transaminase (SGPT) Transaminase (SGOT)
 Increase in Infective hepatitis
and Cardiac problem
ALP  Adults: 44 to 147 U/L (units per liter) GGT Adults: 9 to 48 U/L (units
Alkaline Phosphatase  Children and Adolescents: 120 to 500 Gamma-Glutamyl Transferase per liter)
U/L (due to growth and bone
development)  Normally high in male due to Children: The range can
Prostrate gland vary but is generally higher in
 Modernly increased in children compared to adults.
 Increase in Bone Disease : Very High infective hepatitis
 Increase in Cholilithiasis: High  Highly elevated in alcoholism
 Increase in Hepatic Disease : .
Moderate rise

NTP 2-10 IU/L

Nucleotide phosphatase  Moderate increase in Hepatitis and
highly in biliary obstruction
 In Liver problem: ALT >> AST: Very high in Acute hepatitis
 The normal range of total bilirubin in the blood is typically:
 Total Bilirubin: 0.1 to 1.2 mg/dL, Direct (Conjugated) Bilirubin: 0.1 to 0.3 mg/dL, Indirect (Unconjugated) Bilirubin: 0.2 to 0.8 mg/dL

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ALP: has 6 Isozyme

ENZYME Remarks Enzyme Remarks
Alpha -1 ALP Increase in Obstructive Alpha-2 Heat labile ALP Increase in Infective hepatitis
Jaundice
Alpha -2 Heat Stable ALP  Placental Origin, Normal Pre- Beta ALP  Bone origin
high in Preg. female  Very high in Bone disease
(Regan Isoenzyme )  High in Chronic smoking

Gamma- ALP  Intestinal origin Leucocyte Alkaline  Decrease in Chronic

 Increased in Ulcerative Phosphatase (LAP) myeloid leukemia.
colititis

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MCQS of Clinical Based MCQS

1. A 45-year-old man with a history of heavy alcohol use presents with jaundice and abdominal pain. His liver function tests show:
ALT 95 U/L, AST 180 U/L, ALP 120 U/L, and GGT 350 U/L. Which of the following is the most likely diagnosis?
a) Viral hepatitis b) Alcoholic liver disease
c) Biliary obstruction d) Hepatocellular carcinoma
Answer: b) Alcoholic liver disease

Explanation:
The AST to ALT ratio is greater than 2 (AST 180 U/L, ALT 95 U/L), which is characteristic of alcoholic liver disease. In alcoholic liver
disease, AST is typically elevated more than ALT due to alcohol's effect on mitochondrial enzymes.
GGT (350 U/L) is markedly elevated, which strongly supports alcohol use. GGT is often elevated in chronic alcohol consumption.
ALP (120 U/L) is within normal or mildly elevated limits, which does not point to significant biliary obstruction or liver mass.
Jaundice and abdominal pain are common symptoms in alcoholic liver disease, as alcohol can cause inflammation and damage to liver cells
over time.

2. A 60-year-old woman with a history of diabetes and hypertension presents with fatigue and dark urine. Her LFT results are: ALT
60 U/L, AST 55 U/L, ALP 200 U/L, and total bilirubin 3.0 mg/dL. Which of the following conditions is most likely causing her
symptoms?
a) Hepatitis B b) Cholestasis
c) Hemolytic anemia d) Cirrhosis
Answer: b) Cholestasis

Explanation:
 The patient's liver function tests show a moderately elevated ALP (200 U/L), which is commonly associated with cholestasis or bile duct
obstruction. ALP elevation is often a hallmark of cholestatic conditions.

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 Total bilirubin is elevated (3.0 mg/dL), which indicates an issue with bilirubin excretion, also pointing towards cholestasis, as bile flow
is impaired.
 The patient's ALT (60 U/L) and AST (55 U/L) are mildly elevated, which can occur in cholestasis but are not as elevated as they might
be in acute hepatitis or severe liver disease.

3. A 32-year-old man presents with unexplained weight loss and pruritus. His liver function tests show: ALT 120 U/L, AST 80 U/L,
ALP 400 U/L, and GGT 250 U/L. He also has a history of recent travel to an area with high prevalence of hepatitis A. What is the
most likely diagnosis?
a) Acute hepatitis A infection b) Chronic hepatitis B infection
c) Primary biliary cirrhosis d) Hepatic metastasis
Answer: a) Acute hepatitis A infection

Explanation:
 The patient's ALT (120 U/L) and AST (80 U/L) levels are elevated, which is common in hepatitis. ALT and AST are often elevated in
liver inflammation.
 The ALP (400 U/L) and GGT (250 U/L) are also elevated, suggesting cholestasis, which can be associated with hepatobiliary issues
seen in hepatitis.
 The patient's recent travel to an area with a high prevalence of hepatitis A strongly points toward acute hepatitis A as a likely cause.
 Pruritus (itching) can occur in liver disease due to the accumulation of bile salts in the skin.
 The symptoms of unexplained weight loss and pruritus are commonly associated with liver diseases, and acute hepatitis A can present in
a similar manner.

4. A 50-year-old woman with a history of obesity and diabetes presents with abdominal discomfort. Her LFT results are: ALT 75 U/L,
AST 70 U/L, ALP 110 U/L, and GGT 100 U/L. Ultrasound shows fatty infiltration of the liver. What is the most likely diagnosis?
a) Non-alcoholic fatty liver disease (NAFLD) b) Acute hepatitis
c) Autoimmune hepatitis d) Chronic biliary obstruction
Answer: a) Non-alcoholic fatty liver disease (NAFLD)

Explanation
 The patient has a history of obesity and diabetes, both of which are major risk factors for NAFLD.

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 The LFTs show mildly elevated ALT (75 U/L) and AST (70 U/L) levels, which are common in NAFLD. The ALT is typically slightly
higher than AST in non-alcoholic fatty liver disease.
 ALP (110 U/L) and GGT (100 U/L) are within or near normal ranges, suggesting there is no significant biliary obstruction or ongoing
severe liver inflammation.
 The ultrasound showing fatty infiltration of the liver is a key diagnostic clue for NAFLD.

5. A 28-year-old man with a history of intravenous drug use presents with jaundice and malaise. His LFT results are: ALT 500 U/L,
AST 450 U/L, ALP 100 U/L, and total bilirubin 5.0 mg/dL. Which of the following is the most likely diagnosis?
a) Acute viral hepatitis b) Cirrhosis
c) Hepatic steatosis d) Primary biliary cirrhosis
Answer: a) Acute viral hepatitis

Explanation
 The patient’s ALT (500 U/L) and AST (450 U/L) levels are significantly elevated, which is typical in acute viral hepatitis, where liver
inflammation causes a marked rise in these enzymes.
 Total bilirubin (5.0 mg/dL) is elevated, consistent with jaundice, a common symptom of acute viral hepatitis.
 The patient's history of intravenous drug use increases the likelihood of viral hepatitis, particularly hepatitis B or C, which can be
transmitted through shared needles.
 ALP (100 U/L) is within normal limits, which rules out significant cholestatic diseases or biliary obstruction.

6. A 70-year-old woman presents with confusion and ascites. Her LFTs are: ALT 40 U/L, AST 50 U/L, ALP 200 U/L, and albumin 2.5
g/dL. Her prothrombin time (PT) is prolonged. What is the most likely underlying condition?
a) Liver cirrhosis b) Acute hepatitis
c) Gallbladder disease d) Hepatic metastasis
Answer: a) Liver cirrhosis

Explanation:
 The patient presents with confusion (which could suggest hepatic encephalopathy) and ascites, both of which are classic signs of
advanced liver cirrhosis.
 The LFTs show mild elevations in ALT (40 U/L) and AST (50 U/L), which are often seen in cirrhosis. As the liver becomes
progressively damaged, ALT and AST levels may not be markedly elevated.

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 ALP (200 U/L) is elevated, which can be seen in cirrhosis due to the remodeling of liver architecture and possible cholestasis.
 Albumin (2.5 g/dL) is low, indicating poor synthetic function of the liver, a hallmark of cirrhosis.
 The prolonged prothrombin time (PT) also suggests decreased liver synthetic function, as the liver is responsible for producing clotting
factors.

7. A 45-year-old man with a history of hepatitis C presents for routine follow-up. His liver function tests show: ALT 85 U/L, AST 90
U/L, ALP 150 U/L, and total bilirubin 1.5 mg/dL. He reports feeling well with no new symptoms. What should be the next step in
management?
a) Repeat liver function tests in 3-6 months b) Initiate antiviral therapy
c) Refer for liver biopsy d) Order an abdominal CT scan
Answer: a) Repeat liver function tests in 3-6 months

Explanation
 The patient has a history of hepatitis C but is currently asymptomatic with mild liver enzyme elevations (ALT 85 U/L, AST 90 U/L, ALP
150 U/L). This suggests chronic liver disease but without acute deterioration or significant clinical symptoms.
 Total bilirubin (1.5 mg/dL) is mildly elevated, which can be expected in chronic hepatitis C without acute worsening.
 Given that the patient feels well and there are no alarming signs (e.g., jaundice, significant ascites, confusion, or severe enzyme
derangement), routine monitoring with a repeat of liver function tests in 3-6 months is a reasonable approach to assess ongoing liver
function.

8. A 55-year-old man with a history of chronic liver disease presents with bleeding gums and easy bruising. His LFT results show: ALT
45 U/L, AST 50 U/L, ALP 130 U/L, and prothrombin time (PT) 18 seconds (normal 12-14 seconds). What is the most likely cause of
his bleeding symptoms?
a) Impaired hepatic synthesis of clotting factors b) Portal hypertension
c) Hepatic encephalopathy d) Hepatitis C
Answer: a) Impaired hepatic synthesis of clotting factors

Explanation

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 The patient has chronic liver disease and presents with bleeding gums and easy bruising, which are symptoms related to a
coagulopathy (impaired blood clotting).
 The prolonged prothrombin time (PT) of 18 seconds indicates a deficiency in clotting factors, which are produced by the liver. In
chronic liver disease, the liver’s ability to synthesize these factors is diminished, leading to a higher risk of bleeding.
 The relatively normal ALT (45 U/L) and AST (50 U/L) suggest that the liver injury is chronic rather than acute, supporting the idea that
the bleeding is due to impaired liver function rather than an acute insult.

9. A 40-year-old woman with a history of autoimmune thyroid disease presents with elevated liver enzymes. Her LFTs show: ALT 150
U/L, AST 140 U/L, ALP 300 U/L, and GGT 200 U/L. What is the most likely diagnosis?
a) Autoimmune hepatitis b) Hepatitis A
c) Non-alcoholic fatty liver disease d) Drug-induced liver injury
Answer: a) Autoimmune hepatitis

Explanation
 The patient has a history of autoimmune thyroid disease, which increases the likelihood of another autoimmune condition, such as
autoimmune hepatitis.
 The elevated ALT (150 U/L) and AST (140 U/L) levels suggest liver inflammation, a hallmark of autoimmune hepatitis.
 The ALP (300 U/L) and GGT (200 U/L) levels are also elevated, indicating some degree of cholestasis, which can occur in autoimmune
hepatitis as part of the liver damage process.
 Autoimmune hepatitis commonly coexists with other autoimmune conditions, and the enzyme pattern, along with the patient's history,
points toward this diagnosis.

10. A 50-year-old man presents with dark urine, pale stools, and jaundice. His LFTs are: ALT 65 U/L, AST 70 U/L, ALP 600 U/L, and
total bilirubin 6.0 mg/dL. What is the most likely diagnosis?
a) Biliary obstruction b) Viral hepatitis
c) Hepatocellular carcinoma d) Hemolytic anemia
Answer: a) Biliary obstruction

EXPLANATION

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 The patient presents with dark urine, pale stools, and jaundice, which are classic symptoms of biliary obstruction. The dark urine is due
to increased conjugated bilirubin in the blood being excreted in the urine, while the pale stools result from a lack of bilirubin reaching
the intestines.
 The elevated ALP (600 U/L) is particularly indicative of cholestasis or biliary obstruction, as ALP is an enzyme often elevated in such
conditions.
 Total bilirubin (6.0 mg/dL) is elevated, and in biliary obstruction, the conjugated (direct) bilirubin predominates in the blood, leading to
jaundice.

11. A 60-year-old man with a history of diabetes and hypertension presents with worsening jaundice and abdominal pain. His LFTs are:
ALT 70 U/L, AST 75 U/L, ALP 450 U/L, and GGT 300 U/L. Imaging studies reveal a dilated common bile duct. What is the most
likely diagnosis?
a) Choledocholithiasis b) Acute hepatitis
c) Hepatocellular carcinoma d) Autoimmune hepatitis
Answer: a) Choledocholithiasis

Explanation
 The patient presents with worsening jaundice and abdominal pain, and the imaging studies reveal a dilated common bile duct, which is
strongly indicative of choledocholithiasis (gallstones in the common bile duct).
 The elevated ALP (450 U/L) and GGT (300 U/L) support the presence of cholestasis, which is consistent with bile duct obstruction
caused by gallstones.
 ALT (70 U/L) and AST (75 U/L) are elevated but not as significantly as would be seen in acute hepatitis, suggesting a chronic process
or obstructive issue rather than acute hepatitis.

12. A 45-year-old woman presents with unexplained weight loss, dark urine, and a history of recent travel to a region with high
prevalence of hepatitis E. Her LFTs show: ALT 200 U/L, AST 180 U/L, ALP 120 U/L, and total bilirubin 4.0 mg/dL. What is the
most likely diagnosis?
a) Hepatitis E infection b) Hepatitis B infection
c) Hepatitis C infection d) Autoimmune hepatitis
Answer: a) Hepatitis E infection

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Explanation:
 The patient has a history of recent travel to a region with high prevalence of hepatitis E, which is a key factor in diagnosing hepatitis E
infection.
 ALT (200 U/L) and AST (180 U/L) are significantly elevated, consistent with acute hepatitis.
 Total bilirubin (4.0 mg/dL) is elevated, indicating jaundice, which is typical in viral hepatitis.
 ALP (120 U/L) is only mildly elevated, which is not as high as would be seen in cholestatic conditions, suggesting that the primary issue
is with hepatocellular injury rather than cholestasis.

13. A 50-year-old man presents with abdominal swelling and fatigue. His LFTs are: ALT 30 U/L, AST 35 U/L, ALP 250 U/L, and total
bilirubin 2.5 mg/dL. The patient has a history of chronic hepatitis B. What is the most appropriate next step in management?
a) Perform a liver biopsy b) Start antiviral therapy
c) Repeat liver function tests in 6 months d) Order a hepatitis B viral load test
Answer: d) Order a hepatitis B viral load test

Explanation:
 Given the patient's history of chronic hepatitis B and current symptoms of abdominal swelling and fatigue, it's important to assess the
activity and replication level of the hepatitis B virus to guide further management.
 The elevated ALP (250 U/L) and total bilirubin (2.5 mg/dL) suggest some degree of liver dysfunction or cholestasis, which warrants
further evaluation.
 Ordering a hepatitis B viral load test will help determine the level of viral replication and guide whether antiviral therapy is needed. It
provides crucial information about the disease's activity and informs treatment decisions.

14. A 30-year-old woman with a history of systemic lupus erythematosus (SLE) presents with jaundice and elevated liver enzymes. Her
LFTs are: ALT 80 U/L, AST 85 U/L, ALP 150 U/L, and GGT 110 U/L. What is the most likely diagnosis?
a) Autoimmune hepatitis b) Acute viral hepatitis
c) Non-alcoholic fatty liver disease d) Primary biliary cholangitis
Answer: a) Autoimmune hepatitis

Explanation:
 The patient has a history of systemic lupus erythematosus (SLE), an autoimmune condition that can be associated with other
autoimmune diseases, including autoimmune hepatitis.

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 The elevated ALT (80 U/L) and AST (85 U/L) suggest liver inflammation, which is characteristic of autoimmune hepatitis.
 ALP (150 U/L) and GGT (110 U/L) are also elevated but not as high as in cholestatic conditions like primary biliary cholangitis.
 Autoimmune hepatitis often presents with elevated liver enzymes and can coexist with other autoimmune diseases, making it a likely
diagnosis given the patient’s history.

15. A 65-year-old man presents with a 6-month history of weight loss and fatigue. His LFTs are: ALT 40 U/L, AST 42 U/L, ALP 350
U/L, and total bilirubin 3.5 mg/dL. Imaging studies reveal multiple liver lesions. What is the most likely diagnosis?
a) Hepatic metastases b) Hepatocellular carcinoma
c) Primary biliary cirrhosis d) Chronic hepatitis
Answer: a) Hepatic metastases

Explanation:
 The patient has a history of weight loss and fatigue, which are common symptoms associated with cancer, including liver metastases.
 Multiple liver lesions on imaging are characteristic of metastatic disease rather than a primary liver cancer.
 The elevated ALP (350 U/L) and total bilirubin (3.5 mg/dL) suggest cholestasis or liver dysfunction, which can be seen in metastatic
liver disease due to the disruption of normal liver architecture and bile flow.

16. A 35-year-old woman presents with chronic abdominal pain and jaundice. Her LFTs are: ALT 60 U/L, AST 65 U/L, ALP 220 U/L,
and total bilirubin 4.0 mg/dL. She reports a history of recurrent episodes of biliary colic. What is the most likely diagnosis?
a) Gallbladder disease b) Hepatitis C
c) Cirrhosis d) Autoimmune hepatitis
Answer: a) Gallbladder disease

Explanation:

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 The patient’s history of recurrent episodes of biliary colic and symptoms of chronic abdominal pain and jaundice suggest a problem
with the biliary system, commonly associated with gallbladder disease.
 The elevated ALP (220 U/L) and total bilirubin (4.0 mg/dL) indicate cholestasis, which is consistent with obstructive biliary conditions
such as gallstones.
 ALT (60 U/L) and AST (65 U/L) are mildly elevated, which supports the presence of liver inflammation or biliary obstruction rather
than a primary liver disease.

17. A 50-year-old man with a history of chronic alcoholism presents with confusion and jaundice. His LFTs are: ALT 80 U/L, AST 150
U/L, ALP 120 U/L, and prothrombin time (PT) 20 seconds (normal 12-14 seconds). What is the most likely underlying condition?
a) Liver cirrhosis b) Acute alcoholic hepatitis
c) Hepatitis B infection d) Drug-induced liver injury
Answer: a) Liver cirrhosis
Explanation:
 The patient has a history of chronic alcoholism, which is a significant risk factor for the development of liver cirrhosis.
 Confusion and jaundice are symptoms of advanced liver disease, including cirrhosis. The confusion can be due to hepatic
encephalopathy, a complication of cirrhosis.
 The elevated AST (150 U/L), ALT (80 U/L), and prolonged prothrombin time (PT) of 20 seconds indicate significant liver dysfunction.
Prolonged PT suggests impaired liver synthetic function, a hallmark of cirrhosis.
 ALP (120 U/L) is not as elevated as would be seen in biliary obstruction, which is less consistent with cirrhosis.

18. A 40-year-old woman with a history of obesity presents for routine check-up. Her LFTs are: ALT 100 U/L, AST 90 U/L, ALP 130
U/L, and GGT 150 U/L. She has no symptoms but her liver enzymes are elevated. What is the most appropriate management step?
a) Start treatment with antifibrotic agents b) Initiate weight loss and lifestyle modifications
c) Refer for liver biopsy d) Order hepatitis serology
Answer: b) Initiate weight loss and lifestyle modifications

Explanation:

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 The patient has elevated liver enzymes (ALT 100 U/L, AST 90 U/L), which are indicative of liver inflammation, but she is asymptomatic
and has a history of obesity, a common risk factor for non-alcoholic fatty liver disease (NAFLD).
 Weight loss and lifestyle modifications are the cornerstone of managing NAFLD. Reducing weight through diet and exercise can
significantly improve liver enzyme levels and overall liver health.
 Antifibrotic agents are not typically initiated without evidence of significant liver fibrosis or cirrhosis, which is not indicated by the
provided information.
 Referral for liver biopsy is generally considered if there is a need to assess the extent of liver damage or fibrosis, but this is usually not
the first step in management without further indications.
 Ordering hepatitis serology is useful if there’s suspicion of viral hepatitis, but the patient’s obesity and the pattern of liver enzyme
elevations suggest NAFLD, making lifestyle modifications the first priority.

19. A 55-year-old man presents with ascites and peripheral edema. His LFTs are: ALT 50 U/L, AST 55 U/L, ALP 160 U/L, and albumin
2.8 g/dL. What is the most likely diagnosis?
a) Chronic liver disease b) Acute hepatitis
c) Hepatic steatosis d) Gallbladder disease
Answer: a) Chronic liver disease

Explanation
 The patient presents with ascites and peripheral edema, which are symptoms commonly associated with chronic liver disease due to
portal hypertension and hypoalbuminemia.
 LFTs show elevated ALP (160 U/L) and normal-to-mildly elevated ALT (50 U/L) and AST (55 U/L). Chronic liver disease often leads
to a more stable pattern of liver enzyme elevations compared to acute conditions.
 The low albumin level (2.8 g/dL) indicates impaired liver synthetic function, which is a hallmark of chronic liver disease.

20. A 28-year-old pregnant woman presents with itching and jaundice. Her LFTs show: ALT 70 U/L, AST 65 U/L, ALP 300 U/L, and
total bilirubin 2.0 mg/dL. She is in her third trimester. What is the most likely diagnosis?
a) Intrahepatic cholestasis of pregnancy b) Hepatitis A
c) Acute fatty liver of pregnancy d) Hepatitis B
Answer: a) Intrahepatic cholestasis of pregnancy

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Explanation
 The patient is in her third trimester, and presents with itching (pruritus) and jaundice, which are common symptoms of intrahepatic
cholestasis of pregnancy (ICP).
 The elevated ALP (300 U/L) is characteristic of cholestasis, and in the context of pregnancy, this supports the diagnosis of ICP.
 ALT (70 U/L) and AST (65 U/L) are mildly elevated, which is consistent with liver involvement in ICP. The total bilirubin (2.0 mg/dL)
is also elevated, reflecting cholestasis.

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