How can liver enzyme levels help diagnose liver injury in blunt abdominal trauma. What are the optimal cut-off values for AST and ALT to predict liver injury. How do elevated liver enzymes correlate with injury severity and patient outcomes.

Understanding Blunt Abdominal Trauma and Liver Injury

Blunt abdominal trauma (BAT) represents a common emergency scenario, with intra-abdominal injuries occurring in approximately 13% of cases. The liver, being the second most frequently injured organ in BAT after the spleen, poses significant diagnostic challenges for emergency physicians and trauma surgeons.

Motor vehicle accidents are the primary cause of BAT, followed by falls, physical assaults, sports injuries, and crush injuries. Accurately diagnosing liver injury in BAT patients is crucial for proper management and improved outcomes.

Common Causes of Blunt Abdominal Trauma

• Motor vehicle accidents
• Falls from height
• Physical assaults
• Sports-related injuries
• Crush injuries

Diagnostic Challenges in Liver Injury Assessment

While computed tomography (CT) scans are considered the gold standard for diagnosing liver injury in BAT, they may not be readily available in all healthcare facilities. This limitation has led researchers to explore alternative diagnostic methods, such as evaluating liver enzyme levels, to aid in the timely identification and management of liver injuries.

The Focus Assessment with Sonography for Trauma (FAST) scan, although useful in BAT cases, has limited sensitivity in diagnosing liver injuries and is highly dependent on the operator’s skill. These factors underscore the need for additional diagnostic tools that can complement existing methods and improve the accuracy of liver injury detection.

The Role of Liver Enzymes in Trauma Assessment

Aspartate transaminase (AST) and alanine transaminase (ALT) are liver enzymes that can provide valuable information in cases of suspected liver injury following blunt abdominal trauma. Elevated levels of these enzymes may indicate liver damage and help guide clinical decision-making, especially in settings where advanced imaging techniques are not immediately available.

Why are liver enzymes important in trauma assessment?

Liver enzymes serve as biomarkers of liver cell damage. When liver cells are injured or die, these enzymes are released into the bloodstream, causing their levels to rise. In the context of blunt abdominal trauma, elevated AST and ALT levels can suggest the presence and potentially the severity of liver injury, aiding in rapid triage and management decisions.

Study Design and Methodology

A prospective observational study was conducted at Chitwan Medical College Teaching Hospital (CMCTH) from February 2019 to May 2020. The study aimed to evaluate the role of AST and ALT in patients with BAT and assess their significance in predicting the diagnosis and severity of liver injury.

Key aspects of the study methodology:

1. All patients with BAT were initially assessed by on-duty surgical residents in the emergency department.
2. Patients were categorized into two groups based on imaging and operative findings: those with liver injury and those without liver injury.
3. Statistical analyses were performed to compare clinical characteristics and enzyme levels between the groups.
4. The receiver operating characteristic (ROC) curve was used to calculate optimal cut-off values for AST and ALT in predicting liver injury.

Key Findings and Results

The study included 96 patients admitted with blunt abdominal trauma, of which 38 had liver injury and 58 did not. Several significant findings emerged from the analysis:

Intensive Care Unit (ICU) Stay

Patients with liver injury had a longer median ICU stay compared to those without liver injury. This suggests that liver injuries may lead to more complex clinical courses and require more intensive management.

Enzyme Levels and Liver Injury

A statistically significant difference was observed in the median levels of AST and ALT (p < 0.001) between patients with and without liver injury. This indicates that these enzyme levels can be valuable indicators of liver damage in BAT cases.

Predictive Value of AST and ALT

The area under the ROC curve for AST was 0.89 (95% confidence interval 0.86–0.98) and for ALT was 0.92 (95% confidence interval 0.83–0.97). These results demonstrate that both enzymes are good predictors for identifying liver injury and assessing its severity.

Optimal Cut-off Values for Liver Injury Prediction

One of the most clinically relevant outcomes of this study was the determination of optimal cut-off values for AST and ALT in predicting liver injury:

• AST: ≥ 106 U/l
• ALT: ≥ 80 U/l

Diagnostic Performance of AST ≥ 106 U/l

• Sensitivity: 71.7%
• Specificity: 90%
• Positive Predictive Value: 86.8%
• Negative Predictive Value: 77.6%

Diagnostic Performance of ALT ≥ 80 U/l

• Sensitivity: 77.8%
• Specificity: 94.1%
• Positive Predictive Value: 92.1%
• Negative Predictive Value: 82.8%

These results indicate that ALT ≥ 80 U/l has slightly better overall performance in predicting liver injury compared to AST ≥ 106 U/l, with higher sensitivity, specificity, and predictive values.

Clinical Implications and Application

The findings of this study have several important implications for clinical practice, especially in settings where advanced imaging techniques may not be immediately available:

Rapid Triage and Decision-Making

Elevated AST and ALT levels can serve as quick and accessible indicators of potential liver injury in BAT patients. This information can help emergency physicians and surgeons make faster decisions regarding patient management and the need for further diagnostic procedures or referrals.

Resource Allocation

In resource-limited settings, using liver enzyme levels as an initial screening tool can help prioritize patients who are more likely to have significant liver injuries. This can lead to more efficient use of available resources, including CT scans and specialist consultations.

Risk Stratification

The degree of enzyme elevation may also provide insights into the severity of liver injury, potentially aiding in risk stratification and determining the intensity of monitoring and management required for each patient.

Limitations and Future Directions

While this study provides valuable insights into the use of liver enzymes in diagnosing liver injury in BAT, it’s important to consider its limitations and potential areas for future research:

Sample Size and Generalizability

The study was conducted at a single center with a relatively small sample size of 96 patients. Larger, multi-center studies would be beneficial to validate these findings and ensure their generalizability across different populations and healthcare settings.

Time Course of Enzyme Elevation

Future studies could explore the time course of AST and ALT elevation following trauma, as this information could further refine the diagnostic utility of these markers. Understanding how quickly enzyme levels rise and how long they remain elevated could help in cases where there is a delay between injury and presentation to the hospital.

Combination with Other Biomarkers

Investigating the combined use of AST and ALT with other biomarkers or clinical parameters could potentially improve the accuracy of liver injury prediction. This approach might lead to the development of more comprehensive and reliable diagnostic algorithms for BAT patients.

Long-term Outcomes

Further research into the relationship between initial enzyme levels and long-term patient outcomes could provide valuable prognostic information. This could help guide follow-up care and resource allocation for BAT patients with liver injuries.

In conclusion, this study highlights the potential of AST and ALT as valuable tools in the initial assessment of patients with blunt abdominal trauma. By providing a rapid, accessible method for identifying potential liver injuries, these enzyme levels can complement existing diagnostic approaches and improve patient care, especially in settings where advanced imaging may not be immediately available. As research in this area continues to evolve, the integration of liver enzyme testing into trauma assessment protocols could significantly enhance the management of BAT patients and potentially improve outcomes.

Role of liver enzymes in patients with blunt abdominal trauma to diagnose liver injury | International Journal of Emergency Medicine

• Original Research
• Open Access
• Published: 19 January 2021

• Anup Shrestha 
  ORCID: orcid.org/0000-0002-4945-7250¹,
• Harish Chandra Neupane¹,
• Kishor Kumar Tamrakar¹,
• Abhishek Bhattarai¹ &
• …
• Gaurav Katwal¹ 

International Journal of Emergency Medicine
volume 14, Article number: 7 (2021)
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Abstract

Background

The liver is the second most injured organ following blunt abdominal trauma (BAT) after the spleen. Although the computed tomography (CT) scan is considered as the gold standard for diagnosing liver injury in BAT, it may not readily available in all the hospitals. This study was performed to evaluate the role of aspartate transaminase (AST) and alanine transaminase (ALT) in patients with BAT and its significance in predicting the diagnosis and severity of the liver injury.

Method

The study was conducted in Chitwan Medical College Teaching Hospital (CMCTH) from February 2019 to May 2020. It was a prospective observational study. All the patients with BAT were received by on-duty surgical residents in the emergency department. Based on the imaging and operative finding, patients with liver injury and without liver injury were noted with the associated injury. For comparisons of clinical and grading characteristics between the two groups (liver injury and no liver injury), the chi-squared test was used for categorical variables as appropriate, and the Mann-Whitney U test used for quantitative variables (AST and ALT). The comparisons between more than two groups (grade of injury) were performed using the Kruskal-Wallis test. The receiver operating characteristic (ROC) was used to calculate the optimal cut-off value of AST and ALT.

Results

Among the 96 patients admitted with BAT, 38 patients had liver injury and 58 patients had no liver injury. The median length of the intensive care unit (ICU) stay of patients with liver injury was higher than without liver injury. There was a significant difference in the median level of AST and ALT (< 0.001) between patients with liver injury and no liver injury. The area under the ROC curve of AST was 0.89 (95% confidence interval 0.86–0.98) and of ALT was 0.92 (95% confidence interval 0.83–0.97). The area under the curve demonstrated that the test was a good predictor for the identification of liver injury and also the severity of liver enzymes. The cut-off values for the liver injury were 106 U/l and 80 U/l for AST and ALT, respectively. Based on these values, AST ≥ 106 U/l had a sensitivity of 71.7%, a specificity of 90%, a positive predictive value of 86.8%, and a negative predictive value of 77.6%. The corresponding values for ALT ≥ 80 U/l were 77.8%, 94.1%, 92.1%, and 82.8%, respectively.

Conclusion

In conclusion, we report the optimal cut-off value of AST and ALT for liver injury in BAT as ≥ 106 U/l and 80 U/l, respectively. The elevated level of AST and ALT might assist the emergency physicians and surgeons to timely refer the suspected patients with the liver injury to a tertiary center.

Introduction

Blunt abdominal trauma (BAT) is one of the most common scenarios in the emergency department (ED). The prevalence of intra-abdominal injury in patients with blunt abdominal trauma among is 13% [1]. Motor vehicle accident is one of the major causes of BAT. Other causes include fall injury, physical assault, sports, and crush injury [2]. The liver is the second most injured organ following BAT after the spleen [3]. The clinical diagnosis of liver injury in BAT is a major challenge for emergency physicians and trauma surgeons.

Focus Assessment with Sonography for Trauma (FAST) scan is one of the useful radiological investigations of BAT but has low sensitivity in diagnosing the liver injury and is user-dependent. Therefore, computed tomography (CT) scan is considered as the gold standard for diagnosing liver injury in BAT [4, 5]. CT scan will help to access not only the liver but also other associated organ injuries. Not all the health facilities will have access to the CT scan. In these centers, the elevation of liver enzymes, i.e., aspartate transaminase (AST) and alanine transaminase (ALT), may provide valuable guidance to the emergency physician to suspect liver trauma. Also, the CT scan is expensive and has exposure hazards. It is also difficult to maintain the resuscitation of the hemodynamically unstable patient in the CT scan suite. This might be an extra burden for patients not only in developing countries like Nepal but also for the health system in a developed country. Previous studies have shown that these parameters may assist in the prediction of liver trauma and their severity [6,7,8,9,10]. Patients will be greatly benefitted from on timely referral of the patient to the tertiary trauma center.

So, the objective of this study was to evaluate the role of AST and ALT in patients with BAT and its significance in predicting the severity of the liver injury.

Methods and material

The study was conducted in Chitwan Medical College Teaching Hospital (CMCTH) which was established in 2006. Since then, CMCTH has developed as a multi-specialty tertiary care center in Nepal. The ED receives a huge number of trauma casualties from all over central Nepal. It was a prospective observational study from February 2019 to May 2020.

Inclusion criteria

Exclusion criteria

• Patients with penetrating abdominal trauma

• Patients who died in the emergency department during resuscitation

• Patients who presented late after 24 h of the trauma

• Patients with a history of liver disease

• Patients positive for hepatitis B and hepatitis C surface antigen

Study method

All the patients with BAT were received by on-duty surgical residents in the emergency department. The patient was initially evaluated in the triage, and necessary resuscitation was done according to the Advanced Trauma Life Support (ATLS) protocol. Then, blood samples were sent for hemoglobin, hematocrit, WBC (white blood cell) count, serum AST, and ALT. FAST scan was done and patients with hemodynamic instability were taken for laparotomy. CT scans were done in the rest of the stable patients. The on-duty surgical residents inform the attending surgeon on duty. The first author or the attending surgeon further evaluated the patient and appropriate history with age, gender, mode of injury, and time of trauma of the patient were recorded. Based on the imaging and operative finding, patients with liver injury and without liver injury were noted with the associated injury. The grade of liver injury was done according to the Organ injury Scale by the American Association of Surgery for Trauma (AAST) (2018 version) (Additional file 1: Supplementary Table) [11]. The datasheet was completed by the first author on the same day of admission or within 24 h of the admission. All the patients with BAT were included in the study as they are received and managed by the surgeons of the Department of Surgery of CMCTH. On discharge, the length of total hospital stay, length ICU stay (if admitted in ICU), re-admission in ICU, any blood transfusion, morbidity, and mortality were also recorded.

Data analysis

All statistical analyses and graphics were performed with the SPSS for Windows, version 16.0., Chicago, SPSS Inc. For comparisons of clinical and grading characteristics between the two groups (liver injury and no liver injury), the chi-squared test was used for categorical variables as appropriate, and the Mann-Whitney U test used for quantitative variables (AST and ALT). The comparisons between more than two groups (grade of injury) were performed using the Kruskal-Wallis test. Results were expressed as median (IQR). All p values are two-sided with p values < 0.05 considered statistically significant. The receiver operating characteristic (ROC) was used to calculate the optimal cut-off value of AST and ALT, and using the optimal cut-off value, the sensitivity, specificity, positive predictive value, and negative predictive value were obtained [12].

Ethics statement

The institutional review committee of CMCTH approved this prospective observational study. Written consent was given by patients for the information to be used for the research.

Results

Patient’s demographics

Among the 96 patients admitted with BAT, 38 patients had liver injury and 58 patients had no liver injury. The quantitative data were analyzed in the median because of the skewed distribution. The median age for liver injury was 27 years old. 78.9% of patients with liver injury were male, and motor vehicle accident was the most common mode of injury with 71.1%. Five patients with liver injury had a negative FAST scan. Eight patients with hemodynamic instability were taken directly to the operation room for emergency laparotomy, and the rest of the patients underwent a CT scan. Only 1 patient with liver injury was found during emergency laparotomy. The demographic profile of patients divided into two groups with liver injury and no liver injury is given in Table 1. There were no significant differences in ICU admission rate and days of hospital or ICU stay between the liver injury and no liver injury groups, whereas there was a significant difference in the mortality rate (p < 0.05).

Table 1 Demographic features of liver injury and non-liver injury patients

Full size table

Liver injuries

There were 4 (10.5%) patients with grade I injuries and 11 (28.9%) with grade II injuries, 18 (47.4%) with grade III injuries, and 5 (13.2%) with grade IV injuries. There was no grade V injury reported in our study. Out of 38 patients with liver injury, only 8 (21.1%) patients had isolated liver injury while 30 (78.9%) patients had a liver injury with combined injuries following BAT. Of the 30 patients with combined injuries with liver injury, 18 had a chest injury, 24 had other abdominal injuries, 9 had head plus spine injury, and 10 had pelvis plus extremities injury. The most common associated organ injured with liver injury was the spleen with 37. 5%. The patient with a liver injury with combined other associated injury tended to stay at ICU more days than with isolated liver injuries. Thirty-three (86.8%) patients out of 38 patients were treated conservatively. There was a significant difference in the median of hemoglobin (p < 0.05), hematocrit (p < 0.05), AST (p < 0.001), and ALT (p < 0.001) between different grades of liver injury (Table 2), while there was no difference in total ICU stay and hospital stay. The median of laboratory parameters and total ICU and hospital stay of each grade of liver injury is given in Table 3.

Table 2 Laboratory parameters of patients with liver injury and no liver injury

Full size table

Table 3 Laboratory parameters and outcome of each grade of liver injury (the Kruskal-Wallis test)

Full size table

Main results

The clinical outcome of the patients with liver trauma is given in Table 4. The statical significance in AST and ALT level was seen only in the mortality rate of the patients whereas no significant difference was seen in ICU admission, surgical intervention for liver injury, and blood transfusion category. The receiver operating characteristic (ROC) curve analysis for AST and ALT is showed in Figs. 1 and 2, respectively. The area under the ROC curve of AST was 0.89 (95% confidence interval 0.86–0.98) and of ALT was 0.92 (95% confidence interval 0.83–0.97). The area under the curve demonstrated that the test was a good predictor for the identification of liver injury. According to the ROC curve, the cut-off values for the liver injury were 106 U/l and 80 U/l for AST and ALT, respectively. Using the cut-off value, sensitivity, specificity, positive predictive value, and negative predictive value were calculated (Table 5).

Table 4 Clinical outcome of the patients with liver injury and their AST and ALT levels

Full size table

Fig. 1

ROC curve of AST. ROC receiver operating characteristic, AST aspartate aminotransferase

Full size image

Fig. 2

ROC curve of ALT. ROC receiver operating characteristic, ALT alanine aminotransferase

Full size image

Table 5 Sensitivity and specificity of AST and ALT for liver injury

Full size table

Discussion

Before CT scans were introduced, surgeons use to proceed for laparotomy when they suspected parenchymatous organ injury in BAT [13]. The availability of a modern multi-detector CT scan has helped today’s surgeons tremendously in managing BAT with liver injury conservatively. It not only helps to establish the grade of injury but also helps to detect delayed complications of the high-grade liver in injury [14, 15]. The diagnosis of liver injury is challenging in peripheral centers all over the world where CT is not available. This even applies to developed countries like Japan. To establish the severity of the liver injury is beyond the reach of those emergency physicians and surgeons.

The development of the FAST scan is useful in diagnosing hemoperitoneum, but because of its low sensitivity and specificity, its role in BAT is limited [4, 16]. The role of elevated liver enzymes in predicting the severity of liver injuries is still a matter of dispute. Liver enzymes AST and ALT are present in hepatocytes in high concentration, and following BAT, they leak into blood circulation. Their main function is to catabolize amino acids, permitting them to enter the citric acid cycle. AST is typically found in the liver only but ALT is also found in the heart skeletal muscle, kidney, brain, and RBC [17]. The alteration of ALT and AST in chronic liver injury and drug-induced liver has been extensively studied [18]. Few studies have demonstrated their role as a marker in predicting the severity of liver injury [6,7,8,9,10].

In this prospective observational study, we investigate the role of AST and ALT in the diagnosis of liver injury and its severity. In the recent study, Koyoma et. al. reported the optimal cut-off value of AST and ALT was 109 U/l and 97 U/l respectively for the patients with liver injury in blunt abdominal trauma. They suggested the optimal cut-off value as a predictor and also screening tool for CT scans for the presence of liver injury. Even in a developed country like Japan, they have pointed out the significance of AST and ALT levels for early CT scans and if not available, transfer to the patient to tertiary center [10]. Similar results were reported by Tian et al., Chang et al., Shrivastava et al., and Lee et al. [6,7,8,9]. Shrivastava et al. only compared ALT level whereas other studies included both AST and ALT values.

Our study results also demonstrate that the increased level of AST and ALT predicts the underlying liver injury in patients with blunt abdominal trauma. The median level of grade II liver injury was less than grade I liver injury. This may be because of very few patients with grade I liver injury. The median level of grade III and grade IV was much higher than grades I and II (Table 3). In countries like Nepal where there are few tertiary centers, patients with a high level of AST and ALT should be stabilized and immediately shifted to tertiary care centers. The median of AST and ALT of patients requiring blood transfusion was more than that of the patient not requiring blood transfusion (p < 0.05). This shows that the AST and ALT level is not only important for the prediction of liver injury but also alerts the surgeons about the possible need for blood transfusion. Similarly, the median of AST and ALT in patients with mortality was significantly higher than patients without mortality (p < 0.05). Since only 2 patients expired due to liver injury, the significance of AST and ALT in mortality cannot be suggested. One study reported elevated WBC counts together with elevated AST and ALT are strongly associated with liver injury [19]. But in our study, there was no association between WBC count and liver injury. Overall, the sensitivity, specificity, and positive and negative predictive value of AST and ALT for predicting liver injury were low, so we suggest not using these liver enzymes as a diagnostic tool but to use as a screening tool for possible liver injury. There were some limitations during the study. This was a single institute study and the number of patients with liver injury was relatively small particularly grade I liver injury.

Conclusion

In conclusion, we report the optimal cut-off value of AST and ALT for liver injury in BAT as ≥ 106 U/l and 80 U/l, respectively. In countries like Nepal, where CT scan is not available in every center, the elevated level of AST and ALT might assist the surgeons to timely refer the suspected patients with the liver injury to a tertiary center. In tertiary centers, it might help the surgeons to go for conservative management for minor liver injuries in BAT preventing the exposure hazards of CT scans.

Availability of data and materials

The data that support the findings of this study are available from the corresponding author upon reasonable request.

Abbreviations

BAT:

Blunt abdominal trauma

CT:

Computed tomography

AST:

Aspartate transaminase

ALT:

Alanine transaminase

ED:

Emergency department

CMCTH:

Chitwan Medical College Teaching Hospital

ATLS:

Advanced Trauma Life Support

GCS:

Glasgow coma scale

WBC:

White blood cell

ICU:

Intensive care unit

ROC:

Receiver operating characteristic

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Acknowledgements

The authors thank all the residents and fellows of CMCTH who contributed to the maintenance of the medical record.

Funding

No funding was required for the study.

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1. Department of General Surgery, Chitwan Medical College Teaching Hospital, Bharatpur, Nepal

   Anup Shrestha, Harish Chandra Neupane, Kishor Kumar Tamrakar, Abhishek Bhattarai & Gaurav Katwal

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Contributions

SA and NHC carried out the main manuscript writing. BA and SA collected and analyzed the data. TKK and KG assisted in drafting the manuscript and reviewed the article. All authors read and approved the final manuscript.

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Correspondence to
Anup Shrestha.

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Ethics approval and consent to participate

Written consent was given by patients for the information to be stored in the hospital database and used for the research. This study was approved by our institutional review committee, Chitwan Medical College Teaching Hospital, Chitwan, Nepal.

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Additional file 1.

Supplementary Table.

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What Could Cause Elevated Liver Enzymes in My Dog?

When establishing the health status of pets, we often pursue a battery of tests.  Whilst they may have been explained, you won’t be the first one to wonder what exactly the tests measure and what the numbers mean.

One of the most common tests, along with kidney, is liver function.  These tests are then talked about in terms of liver enzymes.  But what are these liver enzymes and what jobs do they carry out in the body?

Here at My Pet Nutritionist we thought we’d compile a brief guide to liver enzyme function.

But before we get cracking, we need to understand a little more about the liver.

What is the liver?

The liver is one of the largest organs in the body and we call it the powerhouse for good reason.   It has some incredible metabolic functions.

• It converts the nutrients in the diet into substances that the body can use, stores these substances, and supplies cells with them when needed.
• It also takes up toxic substances and converts them into harmless substances or makes sure they are released from the body.

In short, if it’s not working as it should, us or our pets are in a little bit of trouble.

How does it work?

Liver tissue is made up of lots of smaller units of liver cells called lobules. Many canals carrying blood and bile run between the liver cells.

Blood coming from digestive organs flows through the portal vein to the liver, carrying nutrients, medication, and toxic substances. Once they reach the liver, these substances are processed, stored, altered, detoxified, and passed back into the blood or released in the bowel to be eliminated.

In this way, for us humans the liver can remove alcohol from our blood and for both us and our pets, it can get rid of by-products from the breakdown of medications and more!

Another function of the liver, with the help of vitamin K, it produces proteins that are important in blood clotting. It is also one of the organs that break down old or damaged blood cells.

To carry out its job effectively, the liver has enzymes.

What are enzymes?

Enzymes are proteins that speed up processes in the body, you’ll probably be familiar with digestive enzymes; these are compounds which speed up the digestion of food.  So, liver enzymes speed up the processes the liver carries out.

Enzymes are found in liver cells, so the reason you may have heard of elevated enzymes is because damaged or inflamed liver cells can release enzymes into the bloodstream, of which a blood test picks up.

What are the liver enzymes?

Aspartate aminotransferase (AST)

AST is an enzyme found mostly in the heart and liver and to a lesser extent in skeletal muscle. It plays a role in amino acid metabolism – transferring amino groups.  When heart, liver or muscle cells are injured, they release AST into the bloodstream.

ALT, which stands for alanine transaminase, is an enzyme found mostly in the liver. It helps break down proteins for the body to absorb, and therefore also plays a role in converting food into energy in the body. When liver cells are damaged, they release ALT into the bloodstream.

Alkaline phosphatase (ALP)

ALP is an enzyme found in the liver and bone and is important for breaking down proteins. Higher-than-normal levels of ALP may indicate liver damage or disease.

Gamma glutamyl transferase (GGT)

GGT is an enzyme found throughout the body, but it is mostly found in the liver. GGT is typically the first liver enzyme to increase in the blood when any liver bile ducts become blocked or constricted. The primary role of GGT is the extracellular catabolism of glutathione, the major thiol antioxidant in cells, therefore playing a significant role in protecting cells against oxidants produced during normal metabolism.

In short, GGT plays an important role in cellular defence.  This is why GGT levels are often elevated in cases of environmental toxicity.

Low Fat Venison

What can cause elevated enzyme levels?

All dogs should be assessed individually, but there are some common themes which contribute to higher enzyme levels than the general canine population.

Certain Medications

As the liver plays such a role in the metabolism and detoxification of medications, we often find that certain medications can contribute to higher-than-normal levels.

Vaccine Adjuvants

A study carried out in 2012 established an apoptotic effect of the hepatitis B vaccine in the mouse liver.  What this means is that after vaccine administration, cell death occurred in the liver.  As we know, damage to cells in the liver can result in enzymes being released into the bloodstream.

It was thought that the adjuvant aluminum hydroxide played a role in cell apoptosis.  It’s important to acknowledge that this study was carried out on mice, but that’s largely because researchers aren’t queuing up to dissect canine livers after they’ve had a vaccine, thankfully! But it’s important to note that this adjuvant can be found in some vaccines administered to pets.

Food

Aflatoxins (AF) found in food have been associated with increased biomarkers in liver function and oxidative stress.  Aflatoxins are found in cereals and nuts and we can head back to 1952 to understand the true risk of them.

In 1952, an outbreak of fatal liver disease in dogs occurred in the southeastern United States. The disease, termed hepatitis X, was characterised by icterus, lethargy, anorexia, petechiae, epistaxis, and hematemesis.

Affected dogs died one to 14 days after clinical presentation.  The postmortem findings of hepatitis X were noted to be similar to those in swine and cattle after ingestion of mouldy corn.

The disease resulted from exposure to aflatoxins produced by the fungus Aspergillus species. In 1959, the role of aflatoxins in hepatitis X was confirmed when a group of dogs acquired the disease after being fed purified aflatoxin.

Outbreaks of aflatoxicosis sadly do occur. In 2005, there were a number of acute outbreaks of hepatic failure in dogs across the United States which raised suspicion of a food-related toxicosis.

Postmortem examination of the affected dogs revealed severe liver damage suggestive of aflatoxicosis.

Affected dogs consumed food produced by a single manufacturer. Analysis of the pet food confirmed contamination with aflatoxins. The manufacturer issued a recall, and the FDA released an alert, but over the course of the next few weeks more than 100 dogs became intoxicated and died.

How does it happen?

In various tissues, especially in the liver and kidneys, AF are biotransformed and bioactivated by isoenzymes of the multiple function oxidase system or cytochromes.

In short, the enzymes in the liver convert the AF into a reactive oxygen species which can then bind to proteins.  This binding is what can result in toxicity.  They also bind to DNA causing DNA damage and bind to albumin in the blood, which is thought to be the reason for the poor excretion of the toxic compound (leading to build up).

Cereals present an important risk for the health of dogs because they are vulnerable to contamination by AF both in the field and in storage.

Findings Here

Obesity

Metabolic changes accompanying obesity have been intensively studied in humans but are rarely reported in animals.

In humans, we know that metabolic syndrome boasts elevated liver enzymes, can we apply this to dogs?

In 2011, researchers established that various liver enzymes are elevated in the obese dog.

The results indicated that ALT and GGT may have major pathophysiological roles in obesity-related metabolic alterations and should be included as biochemical criteria of metabolic syndrome in canine obesity.

Findings Here

To learn more about obesity, and to find out our top tips on maintaining a lean body mass for your dog, check out our blogs below.

Obesity In Pets – Part One

Obesity in Pets – Part Two

Liver Issues

It goes without saying that the reason we have elevated enzymes in the blood is because there’s something not quite right with the liver cells and therefore function.

If you’d like to learn more about liver issues, check out some of our blogs below:
Liver Shunts In Dogs


Ultimate Natural Guide for Pets: Liver Disease

What Can I Do About Elevated Liver Enzymes?

The reason behind your dog’s enzyme discrepancy could be a number of things, it’s therefore essential to get to the root cause.

We would advocate a fresh food diet whilst limiting exposure to harmful compounds.

Low Copper

Some of our home cooked recipes above may be suitable but we offer a thorough exploration of what’s going on for your pet with a personalised plan, so head over to our services and consider going through the consultation process.

Thanks for reading,

MPN Team

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90,000 Survival after laparoscopic and open liver resections for colorectal cancer metastases. Comparative analysis using pseudo-randomization | Efanov

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3. Varley P.R., Tohme S.T., Chidi A.P., Goswami J. , van der Windt D., Geller D.A., Tsung A. Dissemination of Minimally Invasive Liver Resection for Primary Malignancy: Reevaluating Effectiveness. Ann Surg Oncol. 2018; 25(3):808-817. DOI: 10.1245/s10434-017-6308-2.

4. Fretland Å.A., Dagenborg V.J., Bjørnelv G.M.W., Kazaryan A.M., Kristiansen R., Fagerland M.W., Hausken J., Tønnessen T.I., Abildgaard A., Barkhatov L., Yaqub S., Røsok B.I., Bj Ornbeth B.A. , Andersen M.H., Flatmark K., Aas E., Edwin B. Laparoscopic Versus Open Resection for Colorectal Liver Metastases: The OSLO-COMET Randomized Controlled Trial. Ann Surg. 2018; 267(2):199-207. DOI: 10.1097/SLA.0000000000002353.

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6. Kazaryan A.M., Røsok B.I., Marangos I.P., Rosseland A.R., Edwin B Comparative evaluation of laparoscopic liver resection for posterosuperior and anterolateral segments. Surg Endosc 2011; 25:3881–3889. DOI: 10.1007/s00464-011-1815-x.

7. Kazaryan A.M., Marangos I.P., Røsok B.I., Rosseland A.R., Villanger O., Fosse E., Mathisen O., Edwin B. Laparoscopic resection of colorectal liver metastases: surgical and long-term oncologic outcome. Ann Surg. 2010; 252(6):1005-12. DOI: 10.1097/SLA.0b013e3181f66954.

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Huge liver, lots of bones: 8 amazing facts about newborn babies

• Health

A child is not a reduced copy of an adult, it is a completely different organism. His head is much larger relative to the size of his body, he cannot walk, speak, and has no teeth. Children of every age have their own unique characteristics.

March 13, 2022

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A child is not a small adult. All children’s age is divided into separate periods, each of which is characterized by its own anatomical and physiological features. The younger the child, the greater its differences from the body of an adult. Generally speaking, the main differences between children and adults are obvious – toddlers are characterized by rapid growth and development, while adults are no longer growing. Children have a high level of metabolic processes with a predominance of anabolism – the formation of new cells, the synthesis of nutrients, which is necessary for building a body. In adults, catabolism gradually begins to predominate.

Another important feature of children is the immaturity of the body, organs and systems, so they cannot do much of what is allowed in adults. At the same time, children have improved adaptation to changing conditions, that is, they quickly and easily get used to the new environment. But they perceive adverse environmental factors more sharply – they are more dangerous than radiation, toxins, bad ecology, etc. “Doctor Peter” found out a number of interesting facts about the kids from the pediatrician, nephrologist, chief physician of Euromed Kids Elena Karavaeva.

Baby’s skin is more than just words

Newborns have special skin. She has a thin surface layer, which is easily peeled off from the slightest impact. Therefore, in children, you can often see peeling of the skin on the fingers and feet, where it actively rubs.

Compared to adult skin, the protective function of the skin is lower, but it has a high regenerative ability – all wounds heal faster.

Even children are characterized by low skin elasticity, it gradually increases only by 8-15 years.

See also

They don’t sweat!

Newborn babies don’t sweat. The sweat glands begin to function from 5-6 months, although they are on the body from birth, but they cannot fully work right away. The full development of the sweating function is formed by the age of 7. Before this time, children tend to overheat quickly, especially in the first months of life.

They have 2.5 times more subcutaneous fat and less muscle

The plumpness of babies is touching, in contrast to the same plumpness in an adult. Moreover, in percentage terms, children are incomparably “fatter” than adults. The subcutaneous fat layer in newborns is about 12% (for comparison, in adults, the norm is no more than 5%).

But the crumbs have very few muscles. The muscular system in the first months is poorly developed, accounting for 25% of body weight (40-45% in an adult).

Almost 100 more bones

Children’s bones are softer and more elastic, easily deformed, but resistant to fractures. This is due to the fact that the bones contain a lot of water and few minerals. Instead of part of the bone tissue, cartilage is found in many places. As they grow, they will be replaced by bone tissue. Another interesting detail – children have almost 100 more bones – almost 300 pieces against 206 adults . As the bones grow, they do not disappear anywhere, they just usually grow together into a single, monolithic structure.

Read also

Babies do not have sinusitis

Due to the structure of the nose, young children do not have diseases that schoolchildren, adolescents and adults suffer from. In babies, the nose is small, the nasal passages are narrow, the lower nasal passage is not developed – the air is almost not purified and does not heat up, which is why colds occur more often and easier. Gaimorova, frontal sinuses begin to develop at 2-3 years , before this period, even purely theoretically, children cannot have sinusitis and frontal sinusitis.

They need more oxygen

The child’s body has an increased need for oxygen. In order to provide them with actively working cells, he breathes much more often than adults, and accordingly his heart rate is increased. Respiration and heart rate increased by 2-2.5 times and 1.5-2.0 times, respectively, compared with adults. But with all this, blood pressure in children is much lower than in adults. In order to endure such a load well, to pump blood much faster than in adults, the mass of the child’s heart is naturally larger. In children, it is about 0.8% of body weight, in an adult 0.5%.

The baby will not digest adult food

The salivary glands of the baby begin to function actively from 3-4 months, and from this period there are so many of them that they can literally flow like a stream. Gradually, the volume of saliva levels off. The stomach of the crumbs is located horizontally, in an adult – vertically. Moreover, its volume at birth has the size of no more than a walnut, by the year it reaches the size of an orange.

Less hydrochloric acid is produced in the stomach, the activity of digestive enzymes is lower than in an adult.

Therefore, the baby simply does not digest solid food, he needs food in the form of liquid and puree. The length of the intestine is greater than that of an adult, so the baby takes literally everything that is possible from the food entering his body. Therefore, babies who receive the ideal food – breast milk, can go big once every few days. But only before weaning.

The liver and kidneys are very weak

The liver of children is simply huge, accounting for 4.3% of the body weight in a newborn, while in adults it is 2% of the weight. But the structure of the liver is immature, it is formed only by 7-8 years.