Name: Felicia Reeves ID #: 110 4148

A 40-year-old male returned from South America after a six-month work assignment
complaining of flu-like symptoms, loss of appetite, and pains in the right upper abdomen. His physical examination was unremarkable except for a mild yellowing of his skin and sclera. Blood and urine specimens were taken for laboratory investigation and the following results obtained.

Analyte Total Bilirubin Direct Bilirubin Indirect Bilirubin Total protein Albumin Globulin Alkaline phosphatase [ALP] Alanine Aminotransferase [ALT] Aspartate Aminotransferase GGT Urine Bilirubin Urine Urobilinogen Urine protein S.G. [dipstick/random] Questions: 1. 2. 3. 4.

Patient Value 125 90 35 59 30 29 130 185 300 68 +++ + Negative 1.020

Reference/units 3.4 17.0 mol/L 0 3.2 mol/L 65 -80 g/L 35-55 g/L 20 35 g/L 53-128 U/L 13-40 U/L 15-42 U/L 8.0 63 U/L Negative + [trace] Negative 1.002 1.035

What does the slight yellowing of the skin indicate? 1 Mark What three bits of information can a total bilirubin result provide? [1.5 Marks] What type of hyperbilirubinaemia is occurring? [2 marks] Based on the type of hyperbilirubinaemia, what types of jaundice can now be ruled out R/O? [1.5 Marks] 5. What information can we get from the patients indirect bilirubin? [1 Mark] 6. What information is provided by the transaminases [ALT/AST] in a liver function panel of tests? [2 marks] 7. Calculate the ALT/AST ratio. [1 mark]

8. Based on the knowledge of the answers to 6 and 7, what can be said of the patients tranaaminase results? [3 Marks] 9. What information is provided by the enzymes ALP and GGT in a liver function panel of tests? [ 2 Marks] 10. Based on the knowledge provided by the answer to 9, what can be said of the patients ALP and GGT results? [ 3 Marks] 11. What is the purpose/clinical information provided by total protein and albumin in assessing hepatic function? [2 Marks 12. What information does a normal globulin add to our decision making? [2 Marks] 13. What information does the normal urine protein provide in our assessment of the patient? [1Mark] 14. What type of hepatic jaundice does increased urine bilirubin indicate? [1 Mark] 15. Why is it possible for direct bilirubin to be found in urine and not indirect? [1Mark] 16. What is the general cause of increased levels of urobilinogen in the blood/urine? [1 Mark] 17. What information is provided by a urine Specific Gravity [S.G.] [2 Mark] 18. Based on this, what conclusion can we make about the patient S.G.? [1 Mark] 19. Use your knowledge of the formation, conjugation and excretion of bilirubin to show a diagrammatic illustration of why we have bilirubin in the urine of the patient. [10 Marks] 20. Give the principle for the determination of serum total bilirubin by the modified EvelynMalloy method. [5 Marks] 21. What are the differences and similarity between this method and the Jendrassic-Groff method? [5 Marks] [Total 50 Marks] 1. This indicates Jaundice 2. Total bilirubin can be used to diagnose Jaundice( there is jaundice when total bilirubin is greater than or equal to 34umol/l), it tells if there is a hyperbilirubinemia whether there is a conjugated hyperbilirubnemia(greater than or equal to 50% of total) or a unconjugated hyperbilirubinemia(greater than or equal to 80% of total) 3. The patient has a conjugated hyperbilirubinemia because the direct bilirubin is greater than 50% of the total 4. A pre hepatic jaundice can be ruled out because a hepatic and post hepatic jaundice cause conjugated hyperbilirubinemia 5. The indirect bilirubin assists in determining where the disorder is whether it is hepatic,post hepatic or pre hepatic

6. ALT and AST are markers of hepatocellular function. ALT is more liver specific than AST and found in the hepatocytes this makes it an assessor of hepatocellular dysfunction. AST is found in the cytoplasm and mitochondria of hepatocytes,it is a cell specific enzyme. ALT along with AST helps to determine whether hepatocellular disorder is acute or chronic 7. DeRitis ratio: ALT/AST < 1. 185/300= 0.6 this means that it is an chronic disorder because the . 8. The AST and ALT are markers of hepatocellular function, the patients AST (300) was greater than 3 times the upper limit of reference (423=126) and the ALP (130) was less than 2 times the upper limit of reference(1282=256) this indicates a hepatocellular disorder. 9. ALP and GGT are markers of hepatobilliary function. Both of these enzymes are located on the cell membrane and pointing towards the sinusoids and canaliculus this makes them an assessor of hepatobilliary function 10. The patients ALP and GGT were both increased they were above the reference range this means that the source of the problem is the liver, there is a blockage in the canaliculus and this causes ALP and GGT to back up in the blood instead of going to the intestine 11. Albumin has a long half life; it takes a long time to be reduced by half its value. A low Albumin level indicates chronic disorder. Total protein along with Albumin measures the synthetic function of the liver. 12. Albumin and globulin are both synthesized by the liver, if globulin is normal albumin should be normal. The albumin was decreased indicates that it wasnt synthetic dysfunction of the liver. 13. A normal urine protein means that the loss(decreased) of albumin is not because of kidney dysfunction 14. This indicates regergitation Jaundice 15. The portion of indirect bilirubin in the blood is not released in the urine from the liver it goes to the intestine and becomes urobilinogen 16. Increase urine bilirubin indicates an decrease in liver clearance or an increase in the delivery of urine bilirubin to intestinal tract

17. Urine specific gravity measures the concentration of all chemical particles in the urine. Specific gravity measures the kidney's ability to concentrate or dilute urine in relation to plasma. Urine is a solution of minerals, salts, and compounds dissolved in water, the specific gravity is greater than 1.000. The more concentrated the urine, the higher the urine specific gravity. 18. The patients specific gravity was normal 19. 20. In the modified Evelyn-Malloy method bilirubin couples with diazotized sulphanilic acid to form purple coloured Azobilirubin complex the intensity of purple colour is proportional to the Bilirubin colour in serum. The direct Bilirubin reacts with diazo reagent to form purple coloured Azobilirubin complex which can be measured colorimetrically at 555nm using the spectophotometer. The color of the azobilirubin varies with pH. It is based on the following principle that conjugated (directed) bilirubin is water soluble and therefore will react with diazo reagent in a water solution. Unconjugated (indirect) bilirubin is not water soluble, therefore, methanol is necessary to put the unconjugated bilirubin in solution. So that it can react in the diazo reaction. 21. Similarities Both methods are based on the pairing/combination of diazotized sulphanic acid with bilirubin to produce a coloured compound azobilirubin. Both methods are also affected by a change in pH Differences The accelerator in Evelyn Malloy method is methanol,while in the JendrassicGroff method the accelerator is caffeine The Jendrassic-Groff method less sensitive to sample pH change An acidic solution is used in the Evelyn Malloy method and a Alkaline solution in Jendrassic-Groff method A purple pink coloured compound is formed in the Evelyn Malloy method and a blue green compound in the Jendrassic-Groff Method The Jendrassic-Groff method has adequate optical sensitivity, even for low bilirubin concentrations and has minimal turbidity and a relatively constant serum blank