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

1

2

3

4

56

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