Group D Florendo-Gaspar

 Tests based on detoxification and excretory functions  Tests that measure biosynthetic function  Coagulation factors  Other diagnostic tests Percutaneous liver biopsy Ultrasonography

 Serum bilirubin  Urine bilirubin  Blood ammonia  Serum enzymes  Reflecting damage to hepatocytes  Reflecting cholestasis

 Conjugated Elevation of conjugated bilirubin  Liver or biliary tract disease  Unconjugated Isolated elevation of unconjugated bilirubin  Hemolytic disorders  Genetic conditions  Normal total serum bilirubin concentration: <17 umol/L (1 mg/dL) Up to 30% (0.3 mg/dL) conjugated

 Conjugated bilirubin  Urine dipstick test

 Liver  Striated muscle  Elevated ammonia Severe portal hypertension Portal blood shunting Correlates with outcome in fulminant hepatic failure

 Enzymes that reflect damage to hepatocytes  Enzymes that reflect cholestasis

 Aminotransferases (transaminases) Aspartate aminotransferase (AST) Alanine aminotransferase (ALT) Normally present in the serum in low concentrations Damage to liver cell membrane  increased permeability  greater amounts released into blood Elevation  Up to 300 U/L – nonspecific  > 1000 U/L – extensive hepatocellular injury  ALT ≥ AST in acute hepatocellular disorders  Low level of ALT in alcoholic liver disease

 Alkaline phosphatase (ALP)  5’-nucleotidase (5’NT)  γ glutamyl transpeptidase (GGT) Less specific for cholestasis

 Not totally specific for cholestasis  Elevations > 4 times normal Cholestatic liver disorders Infiltrative liver diseases Bone conditions  Elevation in the absence of jaundice & ↑ aminotransferases Early cholestasis Hepatic infiltration by tumor or granulomata

 Proteins  Coagulation

 Albumin -synthesized exclusively by hepatocytes -half-life: 18-20days -in hepatitis: albumin <3mg/dL should raise the possibility of CHRONIC liver disease -hypoalbuminemia may reflects severe liver damage  Globulin -group of proteins made up of ɣ globulins (immunoglobulins), α and β globulins -increase in concentration of isotypes of ɣ globulins are helpful in recognition of certain chronic liver diseases.

 blood clotting factors are made exclusively in hepatocytes  serum half lives: 6h-5days  measurement of clotting factors measures hepatic synthetic function  PT (prothrombin time)

-blood clotting factors are made exclusively in hepatocytes -serum half lives: 6h-5days -measurement of clotting factors measures hepatic synthetic function -PT (prothrombin time)

TYPE Aminotransferases BilirubinALPAlbuminPT Acute hepatocellular necrosisALT> AST Chronic hepatocellular disorders Alcoholic hepatits CirrhosisAST> ALT Cholestasis CASE: ELEVATED TRANSAMINASE

 Female  50 years old  Dialysis nurse  Elevated ALT-90 IU/L  Known hypertensive on Metoprolol 50mg tab, irregular  BMI 30.4 = Obese  Elevated blood sugar 2y ago, advised exercise, weight reduction  Occasional joint pains – Celecoxib  VS: BP 160/100, afebrile

Salient features of Patient Female 50 year old Dialysis nurse ↑ ALT ↑ BP ↑ blood sugar BMI 30.4 (obese) Joint pains Salient features of Patient Female 50 year old Dialysis nurse ↑ ALT ↑ BP ↑ blood sugar BMI 30.4 (obese) Joint pains Clinical features of NAFLD Female > Male Middle-aged: mean 42, Metabolic Syndrome (Hypertension, DM, ↑ lipids, Obesity) ↑ ALT > AST Fatigue Vague RUQ discomfort ↑ Ferritin History of <20g/d or no alcohol “Fatty liver” Clinical features of NAFLD Female > Male Middle-aged: mean 42, Metabolic Syndrome (Hypertension, DM, ↑ lipids, Obesity) ↑ ALT > AST Fatigue Vague RUQ discomfort ↑ Ferritin History of <20g/d or no alcohol “Fatty liver”

Clinical features of Clinical features of Autoimmune Hepatitis Female Young to middle age Fatigue Hepatomegaly Jaundice Itching Skin rashes Myalgia Arthtalgia Abdominal discomfort Spider angiomas Nausea and vomiting Loss of appetite Dark urine Pale or gray-colored stools Increase ALT Prolonged prothrombin time Clinical features of Clinical features of Autoimmune Hepatitis Female Young to middle age Fatigue Hepatomegaly Jaundice Itching Skin rashes Myalgia Arthtalgia Abdominal discomfort Spider angiomas Nausea and vomiting Loss of appetite Dark urine Pale or gray-colored stools Increase ALT Prolonged prothrombin time Salient features of Patient Female 50 year old Dialysis nurse ↑ ALT ↑ BP ↑ blood sugar BMI 30.4 (obese) Joint pains Salient features of Patient Female 50 year old Dialysis nurse ↑ ALT ↑ BP ↑ blood sugar BMI 30.4 (obese) Joint pains

Salient features of Patient Female 50 year old Dialysis nurse ↑ ALT ↑ BP ↑ blood sugar BMI 30.4 (obese) Joint pains Salient features of Patient Female 50 year old Dialysis nurse ↑ ALT ↑ BP ↑ blood sugar BMI 30.4 (obese) Joint pains