GIT Dr.

Shaf3y

G.I.T. 27 2013

12

ventilator heart lung machine

artificial lung artificial heart artificial liver artificial liver artificial liver 2 Liver

Liver Which is impossible artificial liver

artificial liver Liver

Liver Liver Liver carbohydrates metabolism << liver carbohydrates Liver

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GIT Dr. Shaf3y

Liver glycogen Normal level

glucose

glycogen

Normal

Which means Liver

glycogenesis glycogen glycogenolysis gluconeogenesis amino acids glucose Normal << glucose

metabolism of protein Proteins globulins immune globulins

Liver Liver

immune globulins

albumin Liver alpha one globulin beta globulins transferrin trans cobalamine 2 proteins Immune globulins

Reticuloendothelial system Immune system antibodies Immune globulins

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GIT Dr. Shaf3y

Liver proteins Liver exclusive exclusively << albumins

Liver Liver break down Ammonia liver

Proteins Liver ammonia Urea urea urea Kidney urine Liver

proteins proteins

ammonia proteins Urea Liver ammonia urea Kidney

Metabolism of Fat liver Metabolism of fat liver cholesterol cholesterol Diet Liver Diet blood stream Non estratified cholesterol Diet cholesterol Non estratified cholesterol
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intestine

GIT Dr. Shaf3y

Diet non estratified atherosclerosis blood vessel wall Diet blood vessel atherosclerosis Liver Liver cholesterol cholesterol Liver

Estratrified cholesterol

Liver Liver blood vessel atherosclerosis

Liver

diet diet

cholesterol

Liver Liver

Liver

Diet

cholesterol Liver non estratified cholesterol

Low density non Estratified diet

High density blood vessel

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liver

GIT Dr. Shaf3y

Liver

Liver low density lipoprotein

level Normal

Liver cholesterol level

Normal

totally << cholesterol Non estratified good bad non Estratified bad

Liver cell failure atherosclerosis thrombosis coagulation factors atherosclerosis thrombosis coagulation factors thrombus clotting factor

vitamins activation liver

vitamins liver Vitamin K

vitamin D activation Liver B12 folic acid liver Suicidal << Liver vitamin K activation vitamin D activation folic acid and B12 storage
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GIT Dr. Shaf3y

minerals iron Minerals Liver storage

Metabolism

metabolism functions liver Detoxication Detoxification

urea

ammonia

Liver drugs Liver ammonia

drugs Kidney

Detoxification liver toxins toxins toxins

Detoxification Liver function Coagulation coagulation factors 1972 2,, 7,, 9,, 10

anti coagulant Liver Protein C and protein S coagulation factors anti coagulant

protein C and protein S

bile bile gall bladder directly << intestine fat absorption 600

bile Liver Liver 300 300 bile

Immunological
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GIT Dr. Shaf3y

Portal vein G.I.T. Portal vein G.I.T.

directly sepsis

HCL

HCL

intestine Liver Von Kupffer cell absorption Portal blood Liver

Von Kupffer cell macrophages Portal blood Liver phagocytosis Liver Liver Von Kupffer cell Liver B. Lymphocytes activated Macrophages Other immune system activate T. Lymphocytes activate cytokines

portal vein Von Kupffer immune system activate Liver macrophages Cytokines

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GIT Dr. Shaf3y

Liver functions Endocrinal erythropoietin liver erythropoietin 20 % vitamin D << activate Liver Liver

growth hormone somatomediens Liver Insulin like growth factor

direct growth hormone somatomedines C Liver Liver growth hormone

function anatomy of the liver Liver function

Liver Function
liver function

Liver functions function of the liver testing testing function of the liver test enzymes

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GIT Dr. Shaf3y

Enzymes function of the liver damage of the liver enzymes

function of liver

enzymes

enzymes

SGOT AST Serum Glutamic Oxaloacetic transaminases AST Liver

placenta

intestine

Muscles

RBCs

lung

Kidney

heart

damage Organs Liver disease diagnostic

liver damage Liver damage liver improve

enzyme

as a prognostic marker as a prognostic marker SGOT AST

SGPT ALT Serum Glutamic Pyruvic transminases SGPT ALT G.I.T. Liver G.I.T. Liver More specific for the liver << Liver disease

SGPT
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SGOT

GIT Dr. Shaf3y

SGPT Liver

SGOT

follow up SGPT

SGOT

SGPT Liver Liver

follow up SGOT SGPT

bone bone

Liver Liver

Alkaline phophatase alkaline phosphatase alkaline phophatase

Liver bone

symptoms Liver SGPT SGOT bone alkaline phosphatase Liver SGPT SGOT

SGPT

SGOT bone

SGPT

Liver
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alkaline phosphatase

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GIT Dr. Shaf3y

alkaline phosphatase liver disease Liver disease Liver disease alkaline phosphatase << Normal level k A unit 13 3 Normal level of alkaline phosphatase 13 3 level 30 13 cirrhosis Hepatitis Hepatitis cirrhosis 30 Obstructive jaundice hepatocellular carcinoma alkaline phosphatase

unit KA Unit unit

unit

13

international unit international unit 130

30 130

300 Cirrhosis Hepatitis

300 obstructive jaundice hepatocellular carcinoma

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GIT Dr. Shaf3y

alkaline phosphatase Liver disease Liver disease alkaline phosphatase bone disease bone disease bone disease osteomyelitis, fracture, osteosarcoma, metastasis, Paget disease of the bone, hyper parathyroidism bone disease alkaline phosphatase alkaline phosphatase

5 Nucleotidase

enzyme target 5 Nucleotidase

alkaline phosphatase bone Liver

5 Nucleotidase liver disease bone disease

alkaline phophatase bone liver SGPT Liver bone

SGOT

5 Nucleotidase

Gamma glutamyle transferase Gamma G.T.

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12

GIT Dr. Shaf3y

Gamma Glutamyle Transferase Gamma Glutamyle Transferase ESR of the liver ESR of the liver infection ESR

inflammation

inflammation infection ESR liver disease Gamma G.T. Gamma Glutamyle Transferase liver disease Gamma G.T. liver disease

Follow up go home << Follow up SGOT

Gamma G.T. Hepatotoxic drugs enzyme Hepatotoxic drugs

Gamma G.T. hepato-toxic drug gamma G.T. Alcohol Gamma G.T. absence from alcoholism follow up Alcohol

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GIT Dr. Shaf3y

Gamma G.T.

Gamma G.T. Hepatotoxic drug alcoholism

rejection rejection rejection Gamma G.T. obstructive jaundice obstructive jaundice

Gamma G.T. enzymes

Liver disease 3 at least 40 normal 55

enzymes SGOT SGOT Liver disease Liver enzymes

fatty liver diabetic 75 67 Normal

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GIT Dr. Shaf3y

Obese

15 55 15 Liver biopsy hepatitis marker 40

fatty liver

Liver damage

enzymes enzymes

Liver exhausted Liver

enzymes enzymes

Liver

extensive damage

fulminant hepatic failure 3,000 900 400 Liver enzymes SGOT

Liver enzymes

liver

<< enzymes

bilirubin bilirubin

Liver

<<

enzymes

bilirubin

1
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GIT Dr. Shaf3y

investigations data how to interpret data

Liver

investigations

enzymes Bilirubin

Heme and globin haem Iron Protoporphyrin

bileverdine indirect bilirubin Liver

Protoporphyrin bileverdine Indirect bilirubin direct bilirubin direct bilirubin Intestine stercobilinogen

bile stercobilinogen

Liver Entero-hepatic circulation

urine urobilinogen jaundice Hemolytic Obstructive Hepatocellular

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16

GIT Dr. Shaf3y

Hemolytic Hemolytic hemoglobin heme bileverdine indirect bilirubin

Indirect bilirubin indirect bilirubin liver direct bilirubin

indirect liver intestine bile stercobilinogen stercobilinogen dark stool direct direct

urobilinogen

dark on standing

urine

Dark on standing

dark on standing << Urine whatever Normal color

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GIT Dr. Shaf3y

Oxidation urobilin

dark on standing

dark stool stercobilinogen dark on standing << urine urobilinogen

Obstructive jaundice obstruction Normal Hemoglobin Normal heme Normal bileverdine Normal indirect bilirubin Normal Obstruction direct bilirubin

direct bilirubin is water soluble << direct bilirubin dark urine dark urine Obstructive jaundice direct bilirubin

direct bilirubin bile salts

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GIT Dr. Shaf3y

frothy urine puritis bradycardia bile salts frothy urine

obstructive jaundice hemoglobin heme bileverdine indirect bilirubin direct bilirubin direct bilirubin

direct bilirubin bile salts puritis bradycardia direct bilirubin frothy dark urine stercobilinogen clay stool urobilinogen dark << urine direct bilirubin

Dark

Hepatocellular hepatocellular jaundice Normal << hemoglobin normal << heme normal << bileverdine Normal << indirect bilirubin disease Liver
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GIT Dr. Shaf3y

Indirect bilirubin Indirect

Liver

indirect direct bilirubin Liver cells

hepatocyte

Indirect bilirubin direct bilirubin

Liver disease direct

Hepatocellular jaundice disease indirect

Liver Liver Indirect Liver Liver direct

direct direct

hepatocellular direct

indirect

stercobilinogen direct bilirubin Urobilinogen variant

stercobilinogen stercobilinogen urobilinogen

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GIT Dr. Shaf3y

hepatocellular Liver disease indirect bilirubin stercobilinogen stool

direct bilirubin

Urobilinogen

intestine

direct bilirubin stercobilinogen

urobilinogen

stercobilinogen Liver

Liver disease stercobilinogen

Liver Liver

stercobilinogen Urine Urobilinogen

normal urine Liver Liver disease stercobilinogen

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GIT Dr. Shaf3y

Liver entero-hepatic circulation Liver

variable << urobilinogen Liver direct bilirubin Urine direct bilirubin

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GIT Dr. Shaf3y

Mother of bilirubin father of the enzymes mother of proteins protein

Liver cell failure

coagulation profile

Coagulation profile
Liver coagulations factors 1972 10 9 7 2 PTT PT

intrinsic

extrinsic

1972 << Factors 10 9 7 2 pathways

PTT

PT pathways

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23

GIT Dr. Shaf3y

PT PT prothrombin time extrinsic pathway factor 7 6 liver Liver cell failure PTT PT

extrinsic pathway 3 + 7 << factor Liver

PT PT liver

prothrombin time 6 hours 6 hours

factor 7 half life Half life

coagulation proteins

Protein albumin

Protein
total protein Albumin Globulin

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GIT Dr. Shaf3y

Normal levels

6 8 8 6

globulin

albumin

Normal levels Normal ratio 4/2 4 /2

ratio

21

21 half life

albumin half life albumin

albumin

Which means Hepatitis Normal albumin 3 weeks << at least 3 weeks << at least

acute liver disease albumin chronic liver disease

liver enzymes hepatitis cirrhosis enzymes

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GIT Dr. Shaf3y

Hepatitis albumin cirrhosis << chronic << albumin hepatitis << acute << Normal << albumin albumin chronic acute cirrhosis

albumin chronic

globulins globulins globulins alpha globulins alpha one alpha beta globulins gamma globulins alpha one globulins alpha one antitrypsin COPD congenital emphysema alpha one antitrypsin alpha one antitrypsin deficiency beta globulin alpha two globulin

alpha two

beta bile

alpha two Liver bile alpha two

beta

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26

GIT Dr. Shaf3y

obstructive jaundice

obstructive jaundice This is for theoretical interest not for clinical application

obstructive jaundice

already alkaline phosphatase theoretical

gamma globulins antibodies gamma globulins antibodies chronic liver disease acute B or C gamma globulins Hepatitis acute antibodies

Hepatitis markers acute liver disease immune globulins chronic liver Liver Portal vein Liver

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27

GIT Dr. Shaf3y

bacteremia Immune system activate bacteremia immune globulins

Liver cirrhosis Liver

chronic liver disease Liver liver

bacteremia Immune globulins

antibodies Immune globulins acute and chronic liver disease chronic liver disease acute

gamma globulins chronic liver disease acute

gamma globulins chronic liver disease acute

Immune globulins liver disease Liver disease immune globulin E alcoholic liver disease Immune globulin G chronic hepatitis
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GIT Dr. Shaf3y

Immune globulin M Primary biliary cirrhosis

Ammonia liver cell failure Ammonia liver

Urea

ammonia Liver ammonia ammonia

toxins toxins ammonia detoxication test

test

toxins Liver toxins toxins Liver test Bromosulphthalein (BSP) test << test << obsolete Liver

serum ammonia

clearance test clearance test anti epileptic anti arrhythmia Local anaethesia

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GIT Dr. Shaf3y

Liver say Say

Liver

clearance test

worse patient time

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GIT Dr. Shaf3y

scientific

Liver Liver

clearance test priority Investigations blood glucose blood glucose Liver

glucose

glycogen

Liver

glycogen Hypoglycemia Hypoglycemia liver cholesterol normal << total cholesterol

theoretical interest
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Liver

Non esterified cholesterol

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GIT Dr. Shaf3y

functions alpha feto protein alpha feto proteins Hepato-cellular carcinoma

cancer intra uterine alpha feto protein alpha feto protein Intra uterine

alpha feto protein Intra uterine alpha feto protein albumin albumin albumin alpha feto protein albumin of the fetus

alpha feto protein albumin alpha feto protein disease hepato-cellular carcinoma << Disease Twins pregnancy alpha feto protein hepato-cellular carcinoma

Spina bifida

G.I.T. malignancy

cirrhosis

Hepatitis
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alpha feto protein

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GIT Dr. Shaf3y

meningeocele G.I.T. malignancy cirrhosis spina bifida Open neural crest defect twins pregnancy female alpha feto protein alpha feto protein teratoma dermoid cyst

alpha feto protein cirrhosis follow up hepato-cellular carcinoma cirrhosis alpha feto protein follow up 6 alpha feto protein For any detection Screening

Malignant mass

malignant

benign Ultra sound mass benign mass alpha feto protein Malignant alpha feto protein alpha feto protein cancer

Malignant

benign

mass alpha feto protein malignant

<< Normal << alpha feto protein

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GIT Dr. Shaf3y

Fibrolamellar carcinoma tumor alpha feto protein

mass

alpha feto protein hepato-cellular carcinoma

Malignant

benign

mass

Normal biopsy

marker

Marker Des gamma carboxy prothrombin marker Des gamma carboxy prothrombin fibrolamellar carcinoma

investigations

hepatomegaly

shrunken

Liver

size

splenomegaly Ascites Portal hypertension portal vein dilated obstructive jaundice dilated << bile duct Liver Mass

MRI

CT

More accurate PTC ERCP biliary obstruction

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GIT Dr. Shaf3y

Biopsy from the liver indication biopsy from the liver for unknown reasons << hepatomegaly for unknown reasons << elevated liver enzymes malignant benign mass liver biopsy glycogen storage diseases Liver biopsy contraindications Bleeding tendency

Normal

<< prothrombin time Liver biopsy

platelet count biopsy Markedly shrunken liver Markedly shurken liver Organs Massive ascites biopsy Massive ascites gas intestine floating intestine abdominal wall

biopsy irritable

contraindications Uncooperative patient Hepatic encephalopathy biopsy sedation hepatic encephalopathy P

pre hepatic coma

Irritable

sedation

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GIT Dr. Shaf3y

biopsy liver biopsy local anaethesia general

obstructive jaundice

biopsy bleeding tendency

biliary obstruction

biopsy dilated Liver biliary puncture biopsy biliary peritonitis peritonitis bleeding tendency cirrhosis Liver cell failure

cirrhosis

laparotomy liver Liver Weeping liver Liver Liver Liver cirrhosis

cirrhosis

Liver

cirrhosis Liver Liver Lymphatic obstruction cirrhotic liver Is weeping on itself Liver function
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GIT Dr. Shaf3y

G.I.T. 45 15

2013

www.facebook.com/dr.tafreegh

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