PATHOPHYSIOLOGY OF LABORATORY ABNORMALITIES IN LIVER DISORDERS By : Dr. MONANG SIAHAAN, SpPK(K) Dr.CORIEJATI RITA, SpPK, MM
PATHOPHYSIOLOGY OF LABORATORY ABNORMALITIES IN
LIVER DISORDERS
By :
Dr. MONANG SIAHAAN, SpPK(K)
Dr.CORIEJATI RITA, SpPK, MM
LABORATORY TESTS OF LIVER FUNCTION
TESTS OF EXCRETION FUNCTION
Bilirubin metabolism: 80 % mature RBC 20 % immature RBC, other heme
Hemoglobin heme + globinRES Heme Biliverdin + Co + Fe ++
Bilirubin
Bilirubin binds with albumin (indirect bilirubin)
Bilirubin binds with y/z protein+ glucuronic acid Monoglucuronic bilirubin2 molecule of monoglucuronic bilirubin 1 molecule of diglucuronic bilirubin Mono & diglucuronic Biliar canaliculi bilirubin bile duct
CIRCULA-TION
LIVER
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2
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Bilirubin Mesobilirubinogen
Urobilinogen
Stercobilinogen
Urobilinogen
Urobilinogen urine
Urobilin
Faeces stercobilinogen
Stercobilin
UCB = Unconjugated bilirubin ( bilirubin)
BNG = Bilirubin mono glucuronide ( bilirubin)
BDG = Bilirubin diglucuronide bilirubin)
BR-Albumin conjugates = Bilirubin-Albumin conjugatesbilirubin)
DIFFERENCES BETWEEN DIRECT & INDIRECT BILIRUBIN
DIRECT BILIRUBIN INDIRECT BILIRUBIN* POST HEPATIC * PREHEPATIC
* CONJUGATED * UNCONJUGATED
* POLAR * NON POLAR
* DISSOLVED IN WATER * NON DISSOLVED
* POSITIVE IN URINE * NEGATIVE
* REACTIVE WITH DIAZO * REACTIVE WITH DIAZO WITHOUT ALCOHOL IF THERE IS ALCOHOL
* MONO / DIGLUCURONIDE * PURE BILIRUBIN
• Unconjugated bilirubin=alfa bilirubin
• Monoglucuronida bilirubin= beta bilirubin
• Diglucuronida bilirubin=gamma bilirubin
• Delta bilirubin=Bilirubin tightly bound albumin=irreversible albumin bound
1. BILIRUBIN IN SERUM
Method : MALLOY - EVELYN
PrincipleBilirubin + diazo reagent azobilirubin (red)
Normal value in serum < 1 mg% increased total bilirubin find in :a. Overproductionb. Hepatocellular dysfunctionc. Obstruction of bile duct
2. UROBILINOGEN/UROBILIN
Method :
Urobilinogen Wallace Diamond
Urobilin Schlessinger
Normal :
Morning urine (-)
Day urine (+)
DECREASE UROBILINOGEN
* Bilirubin enter intestine* Renal dysfunction* Urobilinogen production disturbance
INCREASE UROBILINOGEN* Liver dysfunction* Bilirubin overproduction
3. STERCOBILINOGEN / STERCOBILIN
Dark stool stercobilinogen pale stool (acholis) stercobilinogen Find in :* Bile duct obstruction* Diarrhea* Antibiotics p.o.
4. ICTERUS INDEX :
Determination of serum / plasma color as a quantitative bilirubin concentration Normal 4-6 U
5. Bromsulphthalein (BSP) test
- Uncolored substance in acid solution
-Colored within alkaline solution Normal : after 30’ retention 0 – 10% after 45’ retention < 3% Abnormal : after 45’ retention > 5 %
ICTERUS : if serum bilirubin > 2 mg/dl
ICTERUS / HYPERBILIRUBINAEMIA
Unconyugated(80 % indirect bilirubin)
Conjugated (direct bilirubin>>>)
Prehepatic(bilirubinoverproduction)
Hepatic(disturbancesof conjugation & uptake)
Hepatic Post hepatic
Hepatocellular Cholestatic intrahepatal
Extrahepatalobstruction
Unconjugated Prehepatic Hyperbilirubinemia ( hemolytic icterus)
Pathophysiology :Erythrocyte destruction
indirect bilirubin
in serum
direct bilirubin
intestine
Portal vein urobilinogen (stercobilinogen) in stool
liver
in circulation
renal
urine urobilinogen
Unconjugated Hepatichyperbilirubinemia
Pathophysiology :
Uptake & conjugation disturbance
Serum indirect bilirubin
Direct bilirubin
Urine / faeces urobilinogen
Example :
- Gilbert syndrome
- Crigler- Najjar syndrome
Laboratory :
- Icterus with indirect bilirubin
- Decrease urobilinogen
- Decrease stercobilinogen
- Urine bilirubin (-)
Conjugated Posthepatic Hyperbilirubinemia (extrahepatal obstruction icterus)
Etiology : cancer, pancreatitis, lithiasis
Pathophysiology :1. Bilirubin cannot enter the intestine urobilinogen (-)
2. Regurgitation of direct bilirubin bile duct pressure permeability leakage bilirubin into blood circulation
• Laboratories : Total
Partial
a. Icterus with direct bilirubin
b. Faeces urobilinogen - +
c. Urine urobilinogen - +
d. Urine bilirubin + +
Conjugated Hepatic Hyperbilirubinemia
A. Cholestatic type Etiology : - Idiopathic
- Hepatitis virus- Drugs : * largactil
* organic arsenical * methyl testosteron
Pathophysiology = conjugated extrahepatal hyperbilirubinemia
B. Hepatocellular typeEtiology : - acute hepatitis virus
- chronis cirrhosis hepatis
Pathophysiology :
Inflammation
liver cell oedem
Liver cell necrosis pressed cholangioles
increased permeability
Leakage of bilirubin into blood circulation
• Billirubin excretion by hepatosit to canaliculi billiaris decrease find in:
• Rotor syndrome
• Dubin johnson syndrome
Liver function test according to Carbohydrate Metabolism
1. Glucose Tolerance Test2. Fructose " "3. Galactose " "4. Epinephrine " "
Test according to detoxification function
Detoxification can be done :
1. Conjugation : Bilirubin, Na-Benzoat2. Destruction : Barbiturat, morphin3. Combination : ADH, sex-hormone, corticoteroid
Test based on enzymatic system
Categories of serum enzymes according to their behavior inHepatitis and obstructive jaundice :
I. Higher in obstructive jaundice than in hepatitis Alkaline phosphatase Leucine Aminopeptidase 5 Nucleotidase Gamma Glutamyl Transpeptidase
II. Higher in hepatitis than in obstructive jaundice Aspartate Transaminase Alaine Transaminase Isocitric dehydrogenase Ormithine carbamyl Transferase Aldolase Iditol dehydrogenase
III. Normal or only slightly elevated in hepatitis & obstructive jaundice : Lactate dehydrogenase Creatine Phosphokinase Lipase Lecithinase
Amylase
IV. Depressed in hepatitis and normal in obstructiv jaundice : Cholinesterase
LCAT
ALKALINE PHOSPHATASEProduced by bone, liver, bile duct, ect.
ALP
I. Pathologic 1. Bone disease : Paget’ disease, osteosarcoma 2. Liver disease : in cholangiohepatitis. Cholestasis stimulates the synthesis of ALP in the liver 3. Non liver / bone disease : Inflammatory bowel disease, hyperthyroidism, pancreatitis, mononucleosis infectiosa
II. Physiologic In growing children and 3rd trimester pregnancy
ALP in hipophosphatemia
Obstructive jaundice =Total obstruction = 3 - 8 XPartial = 1 - 8 X
Hepatocellular jaundice = 1 - 3 XIsoenzyme of ALP placental is most heat stable
5. NUCLEOTIDASE
* Alkali phosphatase acts only on nucleoside 5"-phosphate, to form adenosine and release inorganic phosphate
* Tissues of the body, secreted by the liver
Highest value :* Post hepatic jaundice (obstructive jaundice)* Intrahepatal cholestasis
Increased 2 - 6 X in hepatobiliary diseases
Normal levels in osseous disease
Reference value :
O : 0,07 - 16,7 µ/l
O : 1,27 - 14,83 µ/l+
GAMMA GLUTAMYL TRANSPEPTIDASE (GGT)
* Transfer (alpha) glutamyl from (alpha) glutamyl peptide to others peptides or amino acid
* Kidney, liver, pancreas Elevated levels : * chronic alcoholism
* patients taking drugs (e.g.phenytoin)
* Reference value =
O : 0,65 - 24,09 mU/mL
O : 1,41 - 14,87 mU/mL +
ASPARTATE AMINOTRANSFERASE(AST/GOT)
* Catalyze the inter conversions of AA and -oxoacids bytransfer amino groups * Cardiac muscular, liver, kidney, pancreas decrease
Reference Value :O : 11 - 26 U/LO : 10 - 20 U/L
Elevated levels in : * Hepatocellular disseases (hepatitis) 10 - 200 x normal* Obstructive Hep* Cirrhosis <10 X Normal* Olcoholic liver
This enzyme increase in leucemia,lymphoma,infark miocardial,renal necrosis,mononucleosis infection
+
ALANINE AMINOTRANSFERASE (ALT)
Catalyze the interconversions of AA and d-oxoacids by transfer of amino groups.
Widely distributed in human tissues but in liver >> heart
Increaced in hepatic & non hepatic disease :
* Hepatocellular 10 - 200 X normal
* Obstructive <10X normal
* Cirrhosis, Metastatic carcinoma of the liver <10X N
* Alcoholic
• De Ritis is ALT and AST ratio
• Normal < 1
• Hepatitis Viral > 1
• Non Hepatitis = 1
• Non liver disseases <1
• ALT more specific than AST for hepatocellular disseases
ISOCITRATE DEHYDROGENASE (ICD)
Catalyzes the oxidative decarboxylation of isocitrate to (alpha) - oxoglutarate
are found in various human tissue Increase in hepatic & non hepatic disease
Hepatocellular : (40X)
Obstructive : (slight)
Cirrhosis : (slight)Myocardial infraction = N
ICD more important than ALT and AST
CREATINE KINASE (CK)
* catalyze the reversible phosphorylation of creatine by adenosine triphosphate (ATP) * In : striated muscle,
brain heart tissues
* Isoenzymes : CK1 (CK BB) CK2 (CK MB) CK3 (CK MM)
* Activity in some diseases :* Diseases of sceletal muscle : Increase* Diseases of heart : increase* Diseases of liver : normal
Normal in serum 100% CK3 Heart 40 % CK2 + 60 % CK3Brain 90% CK1 + 10% CK3
Lactate dehydrogenase (LDH)
* Catalyzes the oxidation of L- Lactate to pyruvate
* 5 Isoenzymes : LDH 1, LDH2, LDH3, LDH4, LDH5
present in all cells of the body :
* Cardiac muscle, LDH1
Kidney, eryth LDH2
* Liver & LDH4
skeletal muscle LDH5
CHOLINESTERASE
hydrolyzes acetylcholine choline + acetic acid
changes in liver diseases :
Parenchymatous :
Obstructive : N
Enzyme Source acethylcholine
Acethyl betamethylcholine
butirilcholine
benzoilcholine
Acethylcholine esterase
RBC + + - -
Choline esterase
Serum/plasma
+ - + +
PROTEIN METABOLISM
Sintezis : albuminefibrinogen in liver(alpha) & B glob
* Albumin & Globulin Reference value :
albumin : 3,5 - 4,5 g/dLglobulin : 2 - 3 g/dL
Albumin - Normal / mildly dicrease in acute Hepatitis (virus/toxic) - Decrease severity & prognosis
GLOBULIN
Elevated levels in liver diseases immune response in active chronic hepatitis & active macromodular cirrhosis & globulinBiliary cirrhossisPosthepatic Jaundice Alpha & Beta Glob
ElectrophoresisAlpha 1 globulin : mucoprotein glicoprotein acute disease with fetoris, cancerAlpha 2 & Beta Glob : lipoprotein
(alpha) glob : antibodyChronic disease
Acute Hepatitis
Albumin & globulin : Normal* If alb < 3 gr/dL without increase wide damage
* If globulin > 3,5 gr/dL without decrease cirrhosin
* If globulin & albumine convalescense
Cirrhosis :- compensated : N- decompensated : alb
glob Obstructive Jaundice :
new : Normalold : albumin
globulin
FIBRINOGEN
is sintezised in liver, may be in RES
Function : blood clotting process
Determination : quantitative
semi quantitative qualitative
Normal : 250 - 400 mg/dL
Decrease in : severe liver disease ( acute hepatic necrosis )
Prothrombin
is synthesized in liverDecrease :
1. Poor Vitamin K in diet2. Vitamin K absorption is lack3. Liver cannot synthesized proth.
Obstructive jaundice : prothrombin can be normalized by parenteral vit. K.Parenchymatous jaundice : prothr cannot be normalized by parenteral vit. K
Prothrombin occurred in severe liver disease ( end stage )
very bad prognose
Prothrombin Time ( PTT ) : 10 - 14 sec.
SPECIFIC PROTEIN
A. Haptoglobin :
- glyco protein
- concentration is expressed as Hemoglobin or
methemoglobin binding capacity
Normal : 100 - 200 mg/dl Hb binding capacity
Increase : post hepatic jaundice
Decrease : hepato - cellular disease
B. Lipoprotein-X (Lp-X)
* in cholestatic jaundice & Lecithin Cholesterol acyl transferase deficiency
* Sensitive determinant for cholestatic (if there is no LCAT deficiency) but cannot differentiate intra / extra hepatal cholestatic
C. Alpha fetoprotein (AFP) - is the principal fetal protein
- in children > 1 year until adult normal : < 30 mg/ml can be detection only by Radioimmuno assay (RIA)
- Gross elevations of AFP serum in Hepatocellular carcinoma
Teratoblastoma testis / ovarium
* Hepato-cellular carcinoma* Teratoblastoma lestis / ovarium
Elevation < 500 mg / ml in
Pancreatic carcioma Pancreas cancer
Colon cancer
Lung cancer
On protein electrophoresis move as fast as alpha 1 globulin
Not for liver function test, but for tumor marker
( monitoring therapy of carcinoma )
On non-neoplastic liver disease :
* Chronic active hepatitis
* alcoholic cirrhosis
* regenerative activy of hepatocyte
D. Ceruloplasmin
* Copper oxidase
* Normal : 34 mg/dl
* Decrease : - Wilson's disease
- Protein Energy Malnutrition
- Nephrosis
* Increase : Chronic infection ( tbc, pneu )
Lupus erythematous
Rheumatic arthritis / fever
Myocardial infarction
Physiological stress
ACUTE HEPATITIS
I. Preicterus stadium
Symptom : fever, anorexia, malaise, abdominal discomfort
Laboratories : Abnormal BSP
Positive CCFT
AST & ALT
Urine urobilinogen : positive
others : normal
II. Icterus Stadium :
Symptom : Icteric, liver tender, afebril
Laboratories : Abnormal liver function tests
III. Post - Icterus Stadium :
The symptoms disappear
Lab. : liver function tests decrease to normal level
serum bilirubin still , negative urine urobilinogen
Hematological lab.
* Leucopeni, lymphopeni & neutropeni in preicteric stage
* Aplastic anemi, rare
* PTT protonged
* ESR on preicteric stage
N on icteric stage
if icteric begin to disappear
N on convalescence stage
CHRONIC HEPATITIS
Chronic inflamation > 6 month
Classification :
1. Chronic persistent hepatitis
2. Chronic lobular hepatitis
3. Chronic active hepatitis
1. Chronic persistent hepatitis
Etiology : Hepatitis B virus
Hepatitis Non A Non B virus
Alcoholism
Unknown
Lab. : Normal serum bilirubin or mildly elevated serum
IgG
2. Chronic lobular hepatitis
Etiology : acute viral Hepatitis like illness
Hepatitis Non A Non B virus
Lab. : increase of transaminases
3. Chronic active hepatitis
Etiology : Hepatitis B virus
Hepatitis Non A Non B virus
Unknown
Lab. : serum bilirubin
transaminases
gamma globulin
HEPATIC CIRRHOSIS
Etiology :
- Hepatitis B, non A - non B virus- Alcoholism- Metabolic : hemochromatosis
diabetes mellitusWilson's disease
- Prolonged intra & extrahepatal cholestatis- Abnormal immunity- Toxin & therapeutic agent
Laboratory : Compensated transminases
GGT
urine urobilinogen
Is a diffuse process with fibrosis and nodule formation. It has
followed hepato-cellular necrosis. Although the causes are
many, the end result is the same
Decompensated :
Urine : urobilinogen
(+) bilirubin
sodium in ascites
Blood : bilirubin
albumin
gamma globulin
transaminases
alkaline phosphatase
cholesterol ester
Normochrom normocyter anaemi, PTT prolonged
HAEMOCHROMATOSISA. PRIMARY HAEMOCHROMATOSIS
Normal Iron Metabolism :
The normal daily diet contains about 10 - 20 mg of iron of
this 1 - 1,5 mg is absorbed depends on body stores more
being absorbed the greater the need
Fasting iron serum is 250 / dl.
The normal total body content of iron is about 4 g., of wich
3 g are present in hemoglobin, myoglobulin , catalase, etc
Storage iron comprises 0,5 g ; of this 0.3 is in the liver.
When its capacity is ezcceded, iron is deposited in other
parenchymol tissues.
Definition :
Primary Haemochromatosin is a metabolism disturbance of elevated iron absorpstion for years.
Etiology : Genetic
Patologi : * A. fibrous tissue reaction is found where even the iron
is deposited
liver intestine
pancreas heart
spleen, gaster brain, nerve
endocrine skin
lab. : - abnormal liver function tests
- serum iron
- transferrin 90 % saturated
- hyperglycemia
HEPATOCELLULAR FAILURE
Disfunction of liver cells can cause several manifestations :
1. Jaundice
2. Hepatic coma
3. Endocrine imbalance
- testicular atrophy - gynecomastia - lost of body hair
- arterial spider - palmar erythem 6.disorderd blood coagulation
4. Fetor hepaticum because some factor blood
5. Ascites : coagulation are synthesa in liver
* serum osmotic coloid ( albumin )
* electrolyte retention ( hormonal imbalance ) * portal vein pressure
Oesterogenin
Oesterogen inactivation
Serologic marker of the Hep B viral:HBs-Ag = Hepatitis B surface antigenAnti HBsAg = anti hepatitis B surface antigenHBcAg = Hepatitis B core antigenAnti HBc = anti Hepatitis B core antigenHBeAg = Hepatitis B envelope antigenAnti Hbe = anti Hepatitis B envelope antigen