Liver Function Tests Abnormalities in Enteric Fever- A Recent Update

Introduction:Enteric fever is still a major health problem in developing countries.The term enteric fever includes typhoid and paratyphoid which is characterised by generalised infection of the reticuloendothelial system and intestinal lymphoid tissue accompanied by sustained fever and bacteremia.Hepatic involvement was known for a long time and it was first described by osler in 1899 who documented cases of typhoid fever with jaundice and hepatomegaly.Aims and objectives:This study was undertaken to observe the hepatic manifestations and study the LFT abnormalities during the course of enteric fever and analyse their clinical significance. Settings: A tertiary hospital based study Patients And Methods: The present prospective study was conducted at M.S.Ramaiah Medical Teaching Hospital.50 patients of enteric fever diagnosed on the basis of clinical history, physical examination, blood culture and widal test were included in the study. :A detailed evaluation of the patients was done with particular reference to hepatic dysfunction. A past history of fever was looked.A detailed clinical examination was carried out particularly for the presence of jaundice, pallor, hepatosplenomegaly, altered sensorium, perforation and bleeding tendencies.The Investigations done were complete hemogram, Liver function tests which included total proteins, albumin, total and direct bilirubin, aspartate amino transferase, alanine amino transferase, alkaline phosphatase and prothrombintime.Urine for routine examination and presence of urobilinogen, bile salt and pigments.Routine blood tests for sugar, urea and creatinine,Blood Culture, Stool Culture, Urine culture.WidalTest. Chest X-ray.Peripheral smear for malaria parasite, Brucella agglutination test and Hepatitis B surface antigen. Bleeding and clotting times. Ultrasonography of abdomen were done in clinically indicated cases. Results: In the present study age of the patients ranged from 14yrs to 60 yrs with a mean age of 21.9yrs and male:female ratio being 3.5:2.Analysis of Liver Function Tests:Serum AST was normal in 28 patients, elevated (More than 2 fold) in 22/50(44%) patients and the range of AST is 4 U/L to 301 U/L.Out of 50 cases of enteric fever, elevated AST of more than two fold was seen in 2 cases in 1 week, 13 cases in 2 week and 7 cases in 3 week. There is statistically significant association between duration of fever and AST levels(X 7.2219; df = 2; P<0.05). Serum ALT was normal in 29 patients, elevated (more than 2 fold) in 21/50(42%) patients and the range of ALT is 3 U/L to 368 U/L was seen in 2 cases in 1 week, 12 cases in 2 week and7 cases in 3 week. There is statistically significant associated between duration of fever and ALT levels (x = 6.3557; df -2 ; P < 0.05). Serum Alkaline Phosphatase (ALP):ALP was normal in 31 patients, elevated to more than 2 fold in 19/50(38%) patients and the range of ALP in 13 U/L to 628 U/L.Out of 50 cases of enteric fever, elevated ALP levels of more than two fold was seen in 2 cases in 1 week, 11 cases in 2 week and 6 cases in 3 week. There is statistically significant association between duration of fever and serum alkaline phosphatase. (x = 8.3882; df-2 ; P<005). Serum Bilirubin level in the study group:Hyperbilirubinemia was found in 5/50(10%) patients (>1.8mg/dl) and the range of bilirubin in these patients is 1.8 to 5.6 mg/dl and predominantly had conjugated hyperbilirubinemia. Serum Albumin :Albumin levels of more than 3 gm/dl were seen in 32 patients, and levels less than 3 gm/d were seen in 18/50(36%) patients.ProthrombinTime:Prothrombin time was done for patients who had total bilirubin >1.8mg/dl. One patient had prothrombin time of more than 1.5 times of control. Conclusion: Abnormal LFT S in enteric fever is seen more commonly in patients presenting in 2 and 3 week of illness.Hepatic dysfunction is common in enteric fever.Salmonella hepatitis was seen in patients with prolonged illness and inappropriate antibiotic use.It increases morbidity and prolongs hospital stay.