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The
liver
performs
thousands of tasks that
impact all body systems.
Liver have two channels
that can supply and oxygen
nutriment : hepatic artery
and hepatic portal vein .
The
corresponding
channels is hepatic vein
and bile ducts.
//
Functions of liver
Excretory function: bile pigments,
bile salts and cholesterol are excreted in
bile into intestine.
Metabolic function: liver actively
participates in carbohydrate, lipid,
protein,
mineral
and
vitamin
metabolisms.
Hematological function: liver is also
produces clotting factors like factor V,
VII. Fibrinogen involved in blood
coagulation is also synthesized in liver.
It synthesize plasma proteins and
destruction of erythrocytes.
//
Storage
functions:
glycogen, vitamins A, D and
B12,and trace element iron
are stored in liver.
//
//
//
bile
capacity:
Galactose
Excretion : Bilirubin
Bilirubin is the main bile
pigment that is formed
from the breakdown of
heme in red blood cells.
The broken down heme
travels to the liver, where it
is secreted into the bile by
the liver.
//
BLOOD
CELLS
Stercobilin
excreted in feces
Hemoglobin
Urobilin
excreted in urine
Globin
Urobilinogen
formed by bacteria
Heme
O2
Heme oxygenase
INTESTINE
reabsorbed
into blood
KIDNEY
CO
Biliverdin IX
NADPH
Biliverdin
reductase
Bilirubin diglucuronide
(water-soluble)
NADP+
2 UDP-glucuronic acid
Bilirubin
(water-insoluble)
via blood
to the
liver
Bilirubin
(water-insoluble)
LIVER
Metabolism of bilirubin
1. Serum Bilirubin:
Normally, a small amount of bilirubin circulates in the blood.
Serum bilirubin is considered a true test of liver function, as it reflects
the liver's ability to take up, process, and secrete bilirubin into the bile.
A. Indirect bilirubin
(normal value = 0.3 - 1.2 mg/dl)
B. Direct bilirubin
(normal value 0.4 mg/dl)
C. Total bilirubin
Normal value for = 0.3- 1.2 mg/dl.
//
no
Direct
bilirubin
yes
Slow and
indirect
Rapid and
direct
small
large
no
yes
yes
no
yes
no
solubility in water
Urobilin
Urobilin is the final product of oxidation of urobilinogen by oxygen in
air. The amount change with the amount of urobilinogen excretion .
//
Bilirubin urine:
Bilirubin is not normally present in
urine and faese since bacteria in intestine
reduce it to urobilinogen.
The kidneys do not filter unconjugated
bilirubin because of its binding to albumin.
Conjugated bilirubin can pass through
glomerular filter.
Bilirubin is found in the urine in
obstructive jaundice due to various causes
and in cholestasis.
Bilirubin in the urine may be detected
even before clinical jaundice is noted.
//
Sample
Indices
Hemolytic
Jaundice
Hepatic
Jaundice
Obstructive
Jaundice
Serum
Total Bil
1mg/dl
1mg/dl
1mg/dl
Direct Bil
Urine
Stool
Indirect Bil
Color
deeper
deep
deep
Bilirubin
Urobilinogen
uncertain
Urobilin
uncertain
Color
deeper
lighter or
normal
Argilous
(complete
obstruction)
//
//
Serum Enzymes
The liver contains thousands of enzymes
These enzymes have no known function
probably cleared by reticuloendothelial cells
liver cells damage entrance of Enzymes into serum
//
//
organ
GOT
GPT
organ
GOT
GPT
heart
156000
7100
pancrease 28000
2000
liver
142000
44000
spleen
14000
1200
skeletal 99000
4800
lung
10000
700
kidney
19000
20
16
91000
GPT:
Normal range: 2-59 U/L
serum
GOT:
Normal range: 10-34 U/L
//
//
Levels of aminotransferases
<300 U/L are nonspecific and may be found in any
type of liver disorder.
AST/ALT ratio
Normal - 1 or slightly > 1
<1 : NASH or hepatitis
without cirrhosis
2-4:ALD
>4 : Wilsonian hepatitis
//
Obstructive jaundice
Aminotransferases not greatly elevated
Exception: passage of a gallstone into the common bile duct
acute biliary obstruction aminotransferases 10002000
decrease quickly liver-function tests rapidly evolve typical of
cholestasis.
//
//
Alkaline phosphatase
ALP is a hydrolase enzyme responsible for removing phosphate
groups from many types of molecules, including nucleotides and
proteins.
Most effective in an alkaline environment
In humans it is present in all tissues throughout the entire body,
but is particularly concentrated in
Liver
Heat-stable :
Bile duct
placenta or a tumor is the source.
Kidney
Heat unstable:
intestinal, liver, and bone
Bone
The placenta.
//
//
Level
of
ALP
is not helpful in
distinguishing
//
5' NT
Sensitive
and
specific
hepatobiliary disorders (HBD)
for
GGT
Inducible microsomal enzyme.
N levels 5- 40 IU/L.
Less specific than 5' NT as a marker for
HBD
Unlike 5' NT, GGT may be released from
many sites beside the hepatobiliary tree.
Bone important source of ALP, has little
GGT thus GGT useful for differentiating
hepatic & osseous sources of ALP
//
lactate dehydrogenase
This test measures the total level of the
enzyme lactic dehydrogenase, also called LDH,
in the blood.
LDH is found in body tissues and organs.
LDH isoenzymes
Tissue or organ injury can release LDH into
the bloodstream, thereby raising the level.
If he or she suspects a heart attack or liver
tissue damage in the body.
Normal range: 115-225 IU/L
//
//
Basis:
For galactose is a monosaccharide, almost
exclusively metabolized by the liver.
The normal liver is able to convert galactose
into glucose.
This function is impaired in intrahepatic disease
and the amount of blood galactose and urine
galactose is excessive.
The liver can be assessed by measuring the
utilization of galactose.
Method :
Oral galactose tolerance test
IV galactose tolerance test(intravenous injection )
//
Result:
Normally or obstructive jaundice:
3gm or less of galactose are excreted in the urine
within 3 to 5 hours and the blood galactose returns to
normal within one hour.
Intrahepatic jaundice:
The excretion amounts to
4 to 5gm or more during
the first 5 hours.
Normal response:
Shows little or no rise in the blood sugar level.
The highest blood sugar value reached during the test
should not exceed the fasting level by more than 30 mg%.
In infectious hepatitis or
parenchymatous
liver
cells damage:
Rise in blood sugar is
greater than above, but the
increases obtained are
never very great.
//
metabolism
of
cholesterol
including
its
//
Synthetic functions
1. Total plasma proteins/ albumin/ globulin/
A:G ratio
2. Formation of prothrombin by liver
//
In infectious hepatitis:
Quantitative estimations of albumin and
globulin may give normal results in the early
stages.
Qualititative changes may be present,in
early stage rise in -globulins and in later
stages -globulins shows rise.
//
//
Immunoglobulins produced by B
lymphocytes
Globulins are increased in chronic
hepatitis and cirrhosis.
In cirrhosis: due to the increased
synthesis of antibodies against
intestinal bacteria.
Cause : cirrhotic liver fails to
clear bacterial antigens that
normally reach through the
hepatic circulation.
//
//
thrombin
Prothrombin
Ca2+, PL
//
Prothrombin index =
x100
PT OF patient
//
//
Blood Ammonia
Produced
During normal protein metabolism
Intestinal bacteria in the colon.
liver plays : detoxification of ammonia by converting it
to urea excreted by the kidneys
Striated muscle
detoxification of
(combination with glutamic acid )
ammonia
//
hepatitis, and
certain
other
autoimmune disorders.
Platelet count:
In cases of chronic liver disease where cirrhosis exists, the
platelet count can be lowered although this can occur due
to many conditions other than liver disease.
//
Fibrinogen
Synthesized exclusively by hepatocytes
Plasma fibrinogen 100-700 mg/dl
Functions polymerizes into long fibrin threads by the
action of thrombin formation of clot
Haptoglobins
Forms stable complexes with free Hb
prevents loss of
iron through urinary excretion, protects kidney from damage
Ceruloplasmin
Binds with copper and helps in its transport and storage
Indocyanine green
This dye is removed by the liver after intravenous injection. A
blood level is obtained 20 min after administration.
Compared with BSP its hepatic clearance is more efficient, and
it is nontoxic.
//
- feto protein
Resembles albumin genetically &
functionally
Formation
sitesyolksac,
hepatocytes, enterocytes
Fetal & neonatal life- major
determinant of plasma oncotic
pressure
1 year of age- albumin largely
replaces AFP
//
//
//
Hepatobiliary imaging
USG, CT scan - 1st line
investigation
ERCP visualization
biliary tract
of
//
Biopsy
Despite advances in serological testing
and imaging, liver biopsy remains the
golden standerd to confirm the
diagnosis of specific liver diseases such
as
Wilson disease
Nonalcoholic steatohepatitis
Assess prognosis in many forms of
parenchymal liver disease such as
chronic viral hepatitis
Evaluate allograft dysfunction in liver
transplant recipients.
//
Complications
Post-biopsy pain with or without radiation to the right shoulder
occurs in up to one-third of patients.
Intraperitoneal bleeding is the most serious complication.
Increasing age, presence of hepatic malignancy, and the number
of passes made are predictors of the likelihood of bleeding, as is
the use of a cutting rather than a suction needle
Pneumothorax may require a chest tube, whereas serious
bleeding may be controlled by selective embolization at
angiography or, if necessary, ligation of the right hepatic artery
or hepatic resection
Biopsy of a malignant neoplasm carries a 13% risk of seeding
of the biopsy track with tumor
//
Liver Test
Abnormal in...
Albumin
Alkaline phosphatase
Aminotransferases
(AST, ALT)
Bilirubin
5 nucleotidase
Cholestasis
GGT
INR
Lactate dehydrogenase Ischemic injury, Epstein-Barr virus infection, hemolysis, solid tumor
Uric acid