Muhammad Nadeem Akbar Khan MBBS, MCPS, FCPS Asst. Prof.

Chemical Pathology
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At the end of this lecture you will be able to: Classify Liver Function Tests Enlist Routine LFTs. Discribe briefly the interpretation of raised levels of transaminases, Alkaline phosphatase, Gama GT in different liver diseases. Describe briefly interpretation of raised serum bilirubin and bilirubinuria

Large chemical factory Central role in metabolic process Carbohydrate Metabolism

Synthesis & storage of glycogen Maintain fasting blood glucose level (glycogenolysis & gluconeogenesis)
Protein Metabolism Synthesis & degradation of proteins (albumin, prothrombin, factor II,VII,IX,X) Amino acid metabolism Urea formation

Lipid Metabolism
Synthesis of cholesterol, phospholipids & lipoproteins Fatty acid metabolism Synthesis of bile acid

Excretion/ Detoxification
Bilirubin & bile acid excretion Drugs detoxification & excretion Steroid hormones inactivation & excretion

Storage
Vitamins (A,D,E, B12) Iron, & other Trace Elements

True LFTs Routine LFTs Specific Tests New Tests

Bromosulphthalein (BSP) excretion test Plasma bile acid levels (Cholic acid and Chenodeoxy-cholic acid): In hepatobiliary disease excretion of bile acids by liver is decreased and plasma level rise Coagulation studies: Clotting Factors II, VII, IX and X are synthesized in liver in the presence of Vit K PT Blood ammonia; Produced in the gut by the action of enteric organisms on dietary proteins and amino acid, is absorbed and transported by portal venous system to the liver, and detoxified and incorporated into urea and amino acids.

In severe liver disease blood ammonia level rises

Plasma bilirubin Plasma albumin

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 Some or all of the following:

Serum bilirubin Urine bilirubin and urobilinogen Serum transaminases (ALT, AST) Serum alkaline phosphatase (ALP) Serum -glutamyltransferase (GGT)

Serum lactate dehydrogenase (LD)

Serum proteins
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Bilirubin Metabolism

Orange yellow pigments

Daily production 250- 300 mg(4- 6 mmol) Serum Bilirubin concentration : <20mol/l
Unconjugated bilirubin/ indirect bilirubin
Water insoluble, must be carried by albumin to liver, normally forms 85% of total bilirubin

Conjugated bilirubin/ direct bilirubin

Water soluble, reaches plasma following its reabsorption from the gut and entry into enterohepatic circulation, may also regurgitate directly back into plasma from liver cells in small amounts

Clinical jaundice does not appear unless the plasma bilirubin concentration is more than two and a half time the upper limit (>50 mol/l)

Hyperbilirubinaemia can be caused by

increased production of bilirubin
impaired metabolism

decreased excretion or combination of these. Unconjugated hyperbilirubinaemia (rarely exceeds 100 mol/l)

Gilbert`s syndrome: Haemolysis

Increased production of Bilirubin which exceeds the capacity of the liver to conjugate and remove it

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Bilirubin:
Bilirubin appears in the urine when plasma level of

conjugated bilirubin rises as in hepatocellular disease and Cholestasis

Conjugated bilirubin : water soluble, appears in urine in often

prior to clinical jaundice

Urobilinogen:
Increases in haemolytic disease, hepatocellular disease &

partial biliary obstruction

Absent in complete obstruction Progress of liver disease: if originally absent and appears,

(total obstruction at first & then some relief)

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AST: Found in hepatocyte cytosol & mitochondria, also found in skeletal and cardiac muscle and pancreas ALT: hepatocyte cytosol: Relatively specific to liver
Liver cell damage results in increased plasma levels of both In hepatitis the ALT level is usually greater than that of AST

If AST is found to be greater than ALT, wide spread hepatic necrosis and

poor prognosis is suggested Both can rise 10- 100 times in acute hepatitis Not >10 times rise in uncomplicated cholestasis. Peak values: 7-12 days, reaching normal values 3-5th week

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Found at sinusoidal surface of hepatocytes, in the microvilli of bile canaliculi and ducts Not specific for liver as it is also found in other body tissues Raised in cholestasis, levels very high, usually greater than three times the upper reference limit Hepatocellular disease, normal or moderately raised but less than three times the upper reference limit, due to swollen hepatocytes Bone & other non-hepatic diseases (malignancy/Reagan enzyme, pregnancy). To identify the source of release of ALP
Isoenzymes / 5'- nucleotidase or / GGT

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 Source: hepatobiliary system Highest in intra-hepatic & post-hepatic biliary obstruction More specific than ALP, ALT & AST in detection of cholestasis &

cholengitis Rises earlier and persists longer Moderate rise :2-5 fold

infectious hepatitis, fatty liver, drug intoxication

High elevations: 5-15 fold Pancreatic malignancies, pancreatitis associated with biliary obstruction, Induced by: Alcohol, barbiturates, phenytoin sodium, warfarin Isolated increase does not require any further evaluation, suggest watch

and repeat only if 3/12 months if other LFTs become abnormal then investigate

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Not part of routine LFTs Useful in:

Isolated hyperbilirubinaemia
Haemolytic disease & megaloblastic anaemia to

differentiate from Gilberts syndrome Very high in hypoxic/ischaemic lesions of the liver (ALT:LD <1.5)
grossly elevated inliver disease associated with

infectious mononucleosis

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Albumin
t 17-20 d, synthesised ~15g/d low level suggests severe liver dysfunction

Not a good indicator of severity of disease

Normal in acute illness, low in chronic disease

Globulins
Hyperglobulinaemia: chronic hepatitis & cirrhosis

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Biochemical Test
Blood ammonia Serum urea 1-antitrypsin -fetoprotein Plasma Caeruloplasmin Iron & ferritin

Clinical Significance
(hepatic failure) (hepatic failure) (neonatal hepatitis & cholestasis, cirrhosis) (CA liver) (Wilsons disease) (Haemachromatosis)
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Hepatitis A:HAV-Antigen
Anti-HAV IgM

Appears in stool during incubation period

Acute infection
Previous infection or vaccination Can be used to test for immunity

Anti-HAV IgG

Hepatitis B: HBs Ag
Anti-HBs
Anti-HBc IgM Anti-HBc IgG

First marker to appear, disappears as the disease resolves, persistance indicates the carrier state

Signals recovery and immunity

in active infection( Appears in window period when HBs Ag is negative in current or prior infection Markers of viral presence and potential infectivity in active infxn

HBe Ag and Ab

HBV-DNA-

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Hepatitis C:
Anti HCV antibodies HCV- RNA

during or after infection

during infection Detectable prior to HCV Ab turning

positive

Hepatitis D: Other hepatitis:

Anti-delta antibodies EBV (IM), CMV immunoglobulins

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Immunoglobulins: Nonspecific -IgG: Ch. active hepatitis, cryptogenic cirrhosis -IgM: Primary biliary cirrhosis, alcoholic cirrhosis -IgA: Alcoholic cirrhosis Specific autoantibodies: Anti- mitochondrialantibodies Anti-nuclearantibodies smooth muscle antibodies

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Acute Hepatitis B Virus Infection with Recovery

Typical Serologic Course

Symptoms HBeAg anti-HBe

Total anti-HBc

Titre
HBsAg IgM anti-HBc anti-HBs

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16 20

24 28 32

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52

100
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Weeks after Exposure

5-Nucleotidase (5-NT) Ornithine carbamoyl transferase (OCT) Glutathione S transferase isoenzyme Carbohydrate antigen 19-9 Type III & type I collagen Galactose elimination capacity (GEC) Aminopyrine breath test (APBT)

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Yellow discolouration of tissues due to bilirubin deposition Clinical jaundice may not be discernible unless the plasma bilirubin concentration is more than two and half times the upper limit of normal i.e., more than 50mol/L

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Prehepatic Jaundice Hepatic jaundice Post -hepatic(cholestatic) jaundice

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Increased bilirubin production (heamolysis)

e.g.,Heridetary spherocytosis, HDN due to Rh incompatibility, ABO incompatibility Ineffective erythropoiesis

*uncojugated hyperbilirubinaemia, no bilirubinuria, other LFTs normal

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Haemolytic Disease of Newborn

Unconjugated hyperbilirubinaemia Passes blood brain barrier Phototherapy and enzyme induction

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Pre-microsomal: Drugs;Rifampicin, which interfere with Bil uptake Microsomal: Prematurity Hepatitis,e.g.Viral or drug induced Gilberts Disease Crigler Najjar Syndrome

Post-microsomal(impaired excretion) Hepatitis Drugs Dubin Johnson syndrome

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Intrahepatic obstruction
Viral hepatitis Drugs

Infiltration
Cirrhosis Cholingitis

Biliary atresia

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Gilberts Disease

Uncertain etiology, Decreased hepatic uptake, harmless Intermittent mild jaundice, Unconjugated hyperbilirubinaemia, Absent bilirubinuria

Crigler Najjar Syndrome

Decrease/ absent conjugation (UDP-glucronyl transferase) Unconjugated hyperbilirubinaemia, Absent bilrubinuria Severe/fatal, Enzyme induction by phenobarbital Chronic fluctuating conjugated hyperbilirubinaemia Defect in biliary excretion, Associated defective porphyrin metabolism, Melanin like pigment in liver
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Dubin - Johnson/Rotar Syndrome

Acute Hepatitis: -Bil, ALT, ALP not> 3 times normal

-Viral hepatitis (A, B, C, D, E, F) and CMV/ EB virus

-Hepatotoxin (alcohol, paracetamol, drugs,)

Chronic Hepatitis (hepatitis lasting >6months)

-CAH
-CPH ALT 2-10 times normal 2 times normal Glob Increased Normal Alb Decreased Normal
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Extrahepatic cholestasis:ALP, Bil, Normal or

slightly raised ALT Cholelithiasis(gall stones) Tumours - Ca head of pancreas, Ca bile duct
Biliary stricture Biliary atresia Cholangitis

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A twenty years old student developed a flulike illness with loss of appetite, nausea and pain in right hypochondrium. On examination the liver was just palpable and was tender. Two days later, he developed jaundice, his urine became darker in colour, and his stool became pale.
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On presentation

1 week later

Normal range

Serum: Bilirubin
Albumin ALT AST ALP GGT Urine:

38mol/L 40 g/L 800 U/L 450 U/L 70 U/L 60 U/L

230mol/L 38 g/L 658U/L 365 U/L 150 U/L 135 U/L

3-20 35-50 < 42 10-50 30-150 < 60

Bilirubin Positive Urobilinog- Positive en

Positive Negative

Negative Negative
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What is the diagnosis

Ans: A case of acute hepatitis

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A 55 years old lady was presented to her family practitioner with a

three month history of epigastric pain radiating into the back, and

not related to meals. She was given antacids but returned one month later with more severe pain and weight loss. Over the past week her urine had become darker in colour and her stools pale. She had also become jaundiced. For examination, apart from the jaundice and signs of recent weight loss, no abnormality was found.

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Sample serum

Analyte Total protein Albumin Bilirubin ALP ALT GGT

Result 72 g/L 40 g/L 380 mol/L 510 U/L 80 U/L 115 U/L

Normal 60-80 35-50 3-20 30-150 < 32 < 60

Ultrasound Examination demonstrated the presence of dilated bile ducts A barium meal and follow through revealed indentation of the second part of the duodenum, by an extrinsic mass, to be a carcinoma of the head of the pancreas.
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Q. What is the cause of raised LFTs

Answer: Cholestatic jaundice (obstructive jaundice) Carcinoma of the head of the pancreas obstructing the common bile duct as it enters the duodenum.
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Q1. A 20 years old student was admitted in medical ward with the complaints of loss of appetite, vomitting and pain in right hypochondrium for the last 05 days. On examination she was jaundiced her liver was just palpable and was tender. Her Urine for Bile salt and Pigment was Positive. Lab investigations showed following results: Serum Bilirubin: 3.6 mg/dl Serum ALT: 577U/L, Serum ALP 310U/l. Serum AST 410U/L.What is the most likely diagnosis?
a. b. c. d. e. Acute viral Hepatitis Chronic Active Hepatitis Chronic persistant Hepatitis Acute obstructive jaundice Alcohalic hepatitis

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A 16 years old girl reported to the hospital with general body weakness and jaundice. On examination she had moderate splenomegaly and her liver was 2 fingures BCM. Urine for bilirubin negative but urobilinogen was increased in the urine. Her lab result are as follows: Serum total Bilirubin: 54 umol/l, Bilirubin Direct10 umol/l, ALT 14U/L, ALP 106U/L. What is the most likely cause of jaundice:
a. b. c. Haemolytic jaundice Hepatocellular jaundice Obstructive jaundice

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