Transcript Presentation - Pakistan Society Of Chemical Pathology

PAKISTAN SOCIETY OF CHEMICAL PATHOLOGISTS
DISTANCE LEARNING PROGRAMME IN CHEMICAL PATHOLOGY
LESSON NO 11
LIVER FUNCTION TESTS
BY
SURG COMMODORE AAMIR IJAZ
MCPS, FCPS, FRCP (EDIN)
PROFESSOR OF PATHOLOGY /
CONSULTANT CHEMICAL PATHOLOGIST
BAHRIA UNIVERSITY MEDICAL &DENTAL COLLEGE /
PNS SHIFA KARACHI
EMQs
Match the answers
(Extended Matching Questions)
a.
Acute viral hepatitis
b. Alcoholic liver disease
c. Biliary atresia
d. Breast milk jaundice
e. Chronic Hepatitis C
f. Congenital
Hyperbilirubinaemia
g. Crigler-Najjar Type I
h. Crigler-Najjar Type II
i.
Dubin-Johnson syndrome:
j.
Gilbert Syndrome
k. Haemochromatosis
l.
Hemolytic Disease of the
newborn
m. Obstructive Liver Disease
n. Rotar Syndrome
o. Wilson’s disease
Q. 1: A 27 years old soldier complained of
generalized symptoms for the last 3 days.
His Serum ALT was more than 2500 U/L on
two occasions but he did not have jaundice.
What is the most probable diagnosis in this patient?
a. Acute viral hepatitis
Hepatic Transaminases
• ALT is mainly a cytoplasmic enzyme
• AST has two fractions :
• Cytoplasmic AST
• Organellar AST
• In Acute Hepatitis, only cell membrane is damaged while
organelles remain intact
• So in Acute Hepatitis ALT is markedly increased as compared to
AST
Hepatic Transaminases (Cont)
• ALT may be the first or only liver marker to rise
• In Chronic Hepatitis AST is a better marker
• AST lacks specificity
• So for diagnosis and monitoring of Chronic
Hepatitis (Hep B and C), ALT can be used.
Neonatal (Physiological) Jaundice
Full Term infants
jaundice lasts for about 10 days with a rapid
rise of serum bilirubin up to 204 µmol/L (12 mg/dL).
Preterm infants
jaundice lasts for about two weeks, with a
rapid rise of serum bilirubin up to 255 µmol/L (15 mg/dL).
Phase two
bilirubin levels decline to about 34 µmol/L
(2 mg/dL) for two weeks, eventually mimicking adult values.
Preterm infants - phase two can last more than one month.
Pathological Neonatal Jaundice
Any of the following features characterizes
pathological jaundice:
• Clinical jaundice appearing in the first 24 hours
• Jaundice lasting more than 14 days of life.
• Increases in the level of total bilirubin by more than 8.5 µmol/L
(0.5 mg/dL) per hour or (85 µmol/L) 5 mg/dL per 24 hours.
• Total bilirubin more than 331 µmol/L (19.5 mg/dL)
• Direct bilirubin more than 34 µmol/L (2.0 mg/dL).
Causes of Pathological Neonatal
Unconjugated Hyperbilirubinemia
• Hemolytic Disease of the Newborn: The most common
cause of pathologic indirect hyperbilirubinemia is
increased bilirubin production due to hemolytic disease
processes
• Decreased Clearance: Congental condition like CriglerNajjar syndrome and Gilbert Syndrome
• Breast Milk Jaundice: A very common cause
• Other Causes e.g. GDM
Q. 2: A 22 years year old medical student was upset to find
that her sclera sometimes look yellow specially when she is fasting
and after taking Panadol for trivial problems. She discussed the
problem with her clinical teacher who got her LFTs. On seeing the
report he assured her that this is due to a benign liver disease
which is very common. Her LFTs were:
Conjugated Bilirubin:
Unconjugated Bilirubin:
5
µmol/L
(<4)
30
µmol/L
(<14)
U/L
ALT
:
22
ALP
:
145
U/L
(< 42)
(85- 306)
Most is the most probable diagnosis in this patient?
j. Gilbert Syndrome
Congenital Casuses of Hyperbilirubinaemia
Unconjugated Bilirubinaemia
Gilbert syndrome:
Crigler-Najjar
Conjugated Bilirubinaemia
Dubin-johnson syndrome:
Rotar Syndrome
Gilbert's Syndrome
• The most common inherited disorder of bilirubin
glucuronidation (9-10% of the adult population)
• Also called "constitutional hepatic dysfunction" and "familial
nonhemolytic jaundice"
• Enzyme Defect: Uridinediphosphoglucuronate
glucuronosyltransferases (UGTs) which is a family of
enzymes that mediate glucuronidation of various
endogenous and exogenous compounds
• Genetic Defect: The mutation is in the promoter region,
upstream to exon 1 of the gene encoding bilirubin-UGT
Q. 3: A 10 days old baby has following LFT :
• Conjugated Bilirubin
:
• Unconjugated Bilirubin:
34
µmol/L
(<4)
378
µmol/L
(<14)
U/L
(< 42)
• ALT
:
54
• ALP
:
745
U/L
(85- 730)
• Albumin
:
49
g /L
(35-50)
What is the most probable diagnosis in this patient?
l. Haemolytic Disease of the
Newborn (HDN)
Haemolytic Disease of the Newborn (HDN)
• HDN is a condition in which the red cells of the fetus or
newborn are destroyed by maternally-derived
alloantibodies.
• These antibodies arise in the mother as the direct result
of a blood group incompatibility between the mother
and fetus,
• For example when Rh(D) negative mother carries an
Rh(D) positive fetus
Incidence of HDN
• In developed world very high incidence
has been reduced due to immunization of
Anti D.
• In Pakistan, exact incidence is not known.
However, in a local study, ABO
incompatibility was known to be the major
cause of HDN (71%)
Crigler-Najjar Syndrome (CNS) Type I
• Very rare; only about 100 cases have been reported.
• Autosomal recessive inheritance.
• Severe neonatal jaundice with Bilirubin Induced
Neurological Damage (BIND) and death within 24
months
• Uncojugated bilirubin is high at 342-770 μmol/L (20-45
mg/dL) with almost absent Conjugated bilirubin
• Phenobarbital has no effect on bilirubin levels.
• Absence of bilirubin glucuronides in bile.
CNS Type II
• More common than type I but still very rare.
• Predominantly autosomal recessive inheritance.
• Unconujgated bilirubin 103-342 μmol/L (6-20 mg/dL).
• Mild persistent jaundice in childhood, without brain
damage.
• Phenobarbital reduces bilirubin levels by ~30%.
• Bilirubin glucuronides present in bile.
Q. 4: A 66 years year old male has
following LFT :
Conjugated Bilirubin
:
334
µmol/L
(<4)
Unconjugated Bilirubin :
34
µmol/L
(<14)
ALT
:
62
U/L
(< 42)
ALP
:
1045
U/L
(85- 306)
Albumin
:
49
g /L
(35-50)
m. Obstructive Liver Disease
Q. 5: A 25 days baby presents with jaundice and
failure to thrive. Some of his live tests show:
• Conjugated Bilirubin
:
35
µmol/L (<4)
• Unconjugated Bilirubin
:
63
µmol/L (<14)
1334
U/L (<385)
• Gamma-glutamyl transpeptidase*:
* also
called Gamma-glutamyl transferase
c. Biliary atresia
Conjugated Hyperbilirubinaemia
Defined as:
• Conjugated bilirubin > 17 µmol/L (1 mg/dl) - when total
Bilirubin is < 85 µmol/L (5 mg/dl)
Or
• Conjugated bilirubin > 20 % - When total Bilirubin is >
85 µmol/L (5 mg/dl)
Biliary Atresia
• It is a progressive, idiopathic, fibro-obliterative
disease of the extrahepatic biliary tree that
presents with biliary obstruction exclusively in
the neonatal period
• It is the most common cause of neonatal
jaundice for which surgery is indicated and the
most common indication for liver transplantation
in children.
Biochemical Findings in Biliary Atresia
• Elevations in bilirubin (conjugated bilirubin
≥ 34 µmol/L (2 mg/dL)
• Mild or moderate elevations in ALT or AST
• A disproportionately increased Gamma
Glutammyl Transferase
Q. 6: A new-born developed jaundice at four days
of life. His serial bilirubin reports showed
following results:
• At 4th day of Life:
Unconjugated Bilirubin:
72
µmol/L
• At 14th day of Life:
Unconjugated Bilirubin:
186
µmol/L
• At 10th week of life
Unconjugated Bilirubin:
10
d. Breast milk jaundice
µmol/L
Breast Milk Jaundice (BMJ)
• It is defined as the persistence of physiologic jaundice beyond
the first week of age.
• Typically starts after the first three to five days of life
• Peaks within two weeks after birth,
• Progressively declines to normal levels over 3 to 12 weeks
• BMJ is a benign condition, needs to be distinguished from
breastfeeding failure jaundice that occurs within the first seven
days of life, which is caused by decrease intake resulting in
excessive weight and fluid loss.
BMJ (cont)
• A factor in human milk that promotes an increase in intestinal
absorption of bilirubin may be responsible.
• Beta-glucuronidase is a candidate substance as it deconjugates
intestinal bilirubin, increasing its ability to be absorbed (i.e,
increasing enterohepatic circulation).
• Approximately 20 to 40 percent of women have high levels of
beta-glucuronidase in their breast milk.
• Blocking the deconjugation of bilirubin through betaglucuronidase inhibition may provide a mechanism to reduce
intestinal absorption of bilirubin in breastfed infants
BCQs
Q. 7: Which of the following hepatic enzymes
has the highest concentration in the
cytoplasm of the liver cells:
a. 5 Nucleotidase
b. Alkaline Phosphatase
c. ALT
d. AST
e. Gamma Glutamyl Transferase
c. ALT
Q. 8: Which of the following enzymes is a
Membrane Bound Enzyme :
a. 5 Nucleotidase
b. Cholinesterase
c. Glutamyl Dehydrogenase
d. Glutathione S-Transferase
e. Isocitrate dehydrogenase
a. 5 Nucleotidase
Membrane Bound Hepatic Enzymes
• Membrane bound hepatic enzymes are:
• Alkaline Phosphatase (ALP)
• Gamma Glutamyl Transferase (Gamma GT)
• 5-prime Nucleotidase
• Increased in Cholestasis
• Bound with cell membranes of endothelial cells of bile
canaliculli
• Obstruction and stasis cause digestion of fat content of
cell membranes.
Q. 9: Which of the following pattern is
most commonly found in Alcoholic
Hepatitis?
a. Raised Alkaline Phosphatase / Gamma GT ratio
b. Raised AST / ALT ratio
c. Raised Bilirubin / Alkaline Phosphatase ratio
d. Raised Bilirubin / ALT ratio
e. Reduced AST / ALT ratio
b. Raised AST / ALT ratio
Q. 10: Serum Bilirubin estimation is one of the most common
investigations carried out in any laboratory. Please answer
following questions regarding this test:
a.
Name various HPLC – based fractions of Bilirubin. How
will you classify these fractions on the basis of Diazo reaction?
b.
Name various methods used for estimation of bilirubin
including a non-invasive method.
c.
Regarding Unconjugated Bilirubinaemia please answer
following questions:
i.
From which ward or department of any hospital most
samples with unconjugated bilirubinaemia are received?
ii.
What are common problems encountered in this
estimation?
iii.
What remedial measure(s) you will suggest to solve these
problems?
Suggested Answer to Q.10 a
Name various HPLC – based
fractions of Bilirubin. How will you
classify these fractions on the basis
of Diazo reaction?
HPLC Based Fractions of Bilirubin
• Alpha (α-bilirubin)
• Beta bilirubin (β-bilirubin)
• Gamma (ϒ-bilirubin)
• δ (delta) -bilirubin
HPLC Based Fractions of Bilirubin
• Alpha (α-bilirubin)
• Beta bilirubin (β-bilirubin)
• Gamma (ϒ-bilirubin)
• δ (delta) -bilirubin
Classification of Bilirubin based on
Diazo Reaction
Direct Bilirubin:
• Beta (monocojugated)
• Gamma (diconjugated)
• Delta bilirubin
Indirect Bilirubin
• Alpha (unconjugated) bilirubin
Suggested Answer to Q.10 b
Name various methods used for
estimation of bilirubin including a noninvasive method.
.
Methods of Bilirubin Estimation
• Diazo method
• DPD
• HPLC
• Capillary electrophoresis methods
• Enzymatic methods
• Direct spectrophotometry
• Transcutaneous measurement of bilirubin (non
invasive)
Suggested Answer to Q.10 c
Regarding Unconjugated Bilirubinaemia
please answer following questions:
i.
From which ward or department of any
hospital most samples with unconjugated
bilirubinaemia are received?
Neonatal Intensive Care Unit (Paeds)
.
Suggested Answer to Q.10 c
Regarding Unconjugated Bilirubinaemia
please answer following questions:
ii. What are common problems encountered
in this estimation?
.
Common Problems in Neonatal Bilirubin Estimation
• Haemolysed samples as HDN is the commonest cause
• Effect of Sunlight: Degradation of Bilirubin
• Phototherapy: May lead to variation in bilirubin concentration
• Estimation with Samples from Adults using the same
standard or using same factor.
• Small sample volume hindering repeating the assay
All these problems lead to frequent inter-departmental conflicts
between Path and Paed Deptt.
Suggested Answer to Q.10 c
Regarding Unconjugated Bilirubinaemia please
answer following questions:
iii. What remedial measure(s) you will
suggest to solve these problems?
.
Remedial Measures for Neonatal Bilirubin Estimation
Haemolysed samples
Since HDN is the commonest cause of Neonatal
Bilirubinaemia, the test has to done on these samples
with haemolysis and one cannot reject these samples.
• Technical measures can be adopted e.g.:
• Sample blanking
• Hb Blanking
• Dilution of samples.
Remedial Measures for Neonatal Bilirubin Estimation
Neonatal Bilirubin as a Separate test:
•
It is essential that a separate test should be created in your
test directory for neonatal samples by the name of “Neonatal
Bilirubin”
•
The Analytical Measurement Range for this test should be
established with much higher upper limit e.g. at 450 µmol/L .
•
The QC used for this test should also at a higher levels e.g.
150 µmol/L and 350 µmol/L.
•
The reference range used for this test should be determined
by estimating bilirubin in an appropriate number (n) of disease
free neonates of your population.
Q. 11: Isolated rise of ALT is a very common and
often puzzling problem a Chemical Pathologist has to
face. Suppose you are working as a Consultant
Chemical Pathologist in a tertiary care hospital lab. In a
weekly meeting your PG Resident has presented
following three patients with isolated rise of ALT to seek
your opinion. Please note she has collected clinical
information about these patients just from the request
forms and has not seen these patients:
Suggested Answer to Q.11 a
Patient No 1: A 44 years known patient of Hepatitic C (Recent
PCR negative for both HCV and HBV) and Diabetes Mellitus has
following LFTs:
• Total Bilirubin
• ALT
:
7
:
µmol/L
(<17)
94
U/L
(< 42)
U/L
• ALP
:
145
• Albumin
:
46
g /L
(85- 307)
(35-50)
a.
Non-Alcoholic Fatty Liver Disease
b.
Lipid Profile, Glucose (F) and USG (with some
interpretation points)
Suggested Answer to Q.11 b
Patient No 2: A 39 years patient has severe fatigability, impotence,
and hepatomegaly. He has following LFTs:
• Total Bilirubin
• ALT
:
14
:
294
µmol/L
U/L
(<17)
(< 42)
• ALP
:
345
U/L
(85- 307)
• Albumin
:
36
g /L
(35-50)
a.
Haemochromatosis
b.
Ferritin, Transferrin Saturation and HFE gene
studies (with some interpretation points)
Suggested Answer to Q.11 c
Patient No 3: A 58 years known patient of Coronary Artery Disease
patient has following LFTs:
• Total Bilirubin
• ALT
:
:
09
µmol/L
(<17)
87
U/L
(< 42)
• ALP
:
233
U/L
(85- 307)
• Albumin
:
47
g /L
(35-50)
a.
Hepatotoxic effect of statins and NAFLD
b.
Lipid Profile to titrate the dose, CK to see the myopathic
effects and tests for NAFLD (with some interpretation points)
Thank You and Best Of Luck