Liver function test

By
Dr. Ali H. Sadiek
Prof. Of Internal Veterinary Medicine
and Clinical Lab. Diagnosis
Faculty of Vet. Medicine, Assiut University
For the undergraduate student of 5th year Internal medicine
 Liver function test
• Liver is the Largest solid organ in the
body.
• It have a Large reserve capacity
• It is Capable of regeneration
 Function of the liver
™Metabolism: fat, CHO, protein, drugs,
hormones.
- Maintenance of normal blood sugar by
providing the source as glycogen
- Synthesis of some of the pl. proteins &
prothrombin
™Filtration: bacteria, endotoxins, viruses,
antigens, byproducts of coagulation
™Storage: fluids, vitamins, minerals
 Liver diseases
1ry liver diseases are uncommon in
domestic animals, with the exception
of Fascioliasis, Fatty liver and
poisoning.
2ndry liver diseases"
‰ Associating other diseases frequently
seen in animals e.g RVF
‰ By spread from another organs e.g.
Lung abscess, T.B. RVF, etc.
 Liver diseases either:
1- Acute diseases (Obstructive or non)
2- Chronic dis. (Obstructive or non)
Liver diseases either:
• Localised: T.B. Cysts, Abscess
• Diffused: Hepatitis or hepatosis.
• Inflammatory or Non Inflam.
 Functional disorders resulting
from liver diseases are due to:
• Injury of hepatic cells and leakage of its
secretion (↑ALT, AST, ADH).
• Shrinkage of functional mass of the
Liver due to atrophy, fibrosis or cancer
(↓levels of Albumin, prothrombin).
• Obstruction of bile ducts (↑Bilirubin,
AlP, GG).
• Change in Vankupfer cell activities.
 Signs of liver and billiary disease
1- Jaundice
2- Nervous signs.
3- Edema.
4- Digestive Troubles
(Diarrhea/constipation)
5- Photosensitization.
6- Hemorrhagic diathesis.
 Signs of liver and billiary disease
7- Abd. Pain.
8- Change of Liver size.
9- Displacement of liver.
10- Rupture of liver.
11-Black liver in sheep.
12- Anorexia, vomition, emaciation,
anemia
Normal appearance
Fatty liver
Submandibular edema (Bottle Jaw)
Submandibular edema (Bottle Jaw)
Photosensitization
Photosensitization
Photosensitization
 Diagnosis of liver disease
• Case history:
• Signs:
• X-ray.
• Abdominal sonography
• Liver function tests
• Liver biopsy
 Clinical significance of LFT.
• Conformation of liver diseases, its
severeity, taking in consideration
hepatic huge compensatory power.
• Differentiation of types of Jaundice.
• Therapeutic follow-up and evaluation of
prognosis.
• Evaluation of the influence of other
systemic diseases on liver e.g renal,
cardiac, malignancies, toxicities etc.
 Classification of liver function tests.
• No single test is specific, not very
sensitive (cirrhosis) or specific (non-
hepatic factors).
2 categories - Tests that assess:
1. Synthetic Function tests.
2. Liver Damage tests.
a. Hepatocellular disease
b. Cholestastic disease
 I- Synthetic function: Prothrombin:
Pl. protein synthesized by the liver.
Prothrombin Prothrombin INR
time conc

Normal 12-13 sec 100 % 1

Liver
disease,
Vit. K
deficiency
 I- Synthetic Function
1-Prothrombin
↑ prothrombin time, ↓Prothr. conc ↑ INR,
■ substantial impairment
not specific for liver disease
give Vitamin K:
- responds Vit. K deficiency
- unresponsive liver
 I-Synthetic Function
2-Albumin
Albumin
Normal serum Albumin: 35-45 mg/dl.
Albumin level decrease in:
- Chronic affections e.g Liver fascioliasis,
Liver cirrhosis, fatty liver, Cancer
Normal level couples with abnormal
transaminases suggests acute process
viral hepatitis or choledocholithiasis)
 Causes of Low Serum Albumin
and Total Protein
• Malnutrition
• Liver disease
• Nephrotic syndrome
• Protein losing enteropathy.
 II- Excretory function
1- Bilirubin
Serum bilirubin
• Direct bilirubin or conjugated
• Indirect bilirubin or unconjugated (free)
Urinary bile pigments
• Urine bilirubin (mainly conjugated)
- Normally absent in urine
- Its presence : Hepatitis, obstructed duct
• Urobilinogin (free birubin) :
- Its presence means open bile duct
- Its increase : hemolysis of RBCs
 Normal serum Total & Direct
Bilirubin
Cattle 0-0.5 0-0.2 Mg/dl

Sheep 0-0.4 0-0.2 Mg/dl

Camel 0-0.6 0-0.25 Mg/dl

Horse 0-2.0 0-0.5 Mg/dl

Dogs 0-0.3 0-0.1 Mg/dl

 Hyperbilirubinemia
Physiological:
• Lipid mobilization, Fasting horses
• Inability of liver cells to metabolize
bilirubin.
Pathological:
• Excessive Hemolysis of RBCs
(increased free bilirubin)
• Hepatitis (Increased direct & indirect
bilirubin)
• Obstruction of bile duct: Excess direct
and mild indirect bilirubin
 Elevated Direct Bilirubin
Normal level < 0.2 mg/dl
• Biliary obstruction
• Hepatocellular disease
 III-Tests based on excretion of foreign
dyes.
™ It is of little clinical significance, but it
is a good indicator for liver function.
™ BSP or Rosbengal or endothiazine
injectd iv in 5mg/kg bwt.
™ Blood sample drawn every 5 min.
™ Value of dye in each correlated
negatively with liver capacity to get
ride the dye.
IV-Others Tests depend on the specific
biochemical function of the liver

• Galactose Tolerance test.

• Cholesterol level in blood.
• Ammonia, urea, indole etc
 V- Tests depends on enzymatic
activity of the liver

• Increased levels indicate hepatic

cell injury, its necrosis or increased
permeability e.g. AST, ALT, LDH.
• Increased ALP , GGT means bile
obst.
• Decreased level means disturbance
of its production in liver e.g Choline
esterase.
 Enzymes of clinical importance in
liver diseases
1 – Aspartate aminotransferase (AST )
2 – Alanine aminotransferase (ALT)
3 – Gamma Glutamyle Transpeptidase (GGT)
4- Arginase (Arg)
5 – Sobitol dehydrogenase (SDH)
6 – Lactate dehydrogenase (L.D.H)
7 – Alkaline phosphatase (ALP)
 Aminotransferases
• Enzymes that leak when liver cells
damaged
ALT = more specific for liver disease in
human
AST:ALT ratio: >2:1 alcoholic liver disease
• ALT>AST pyridoxine (B6) deficiency:
• Alcohol causes mitochondrial injury
• AST: cytosol & mitochondria
 Aminotransferases
• levels don’t correlate with degree of damage
• typical ranges
 Cholestatic Disease
Cholestasis = lack of bile flow
• jaundice: pruritis, weight loss
‰Extrahepatic: obstruction in bile duct eg.
strictures, stones, tumors
‰Intrahepatic : impairment bile
formation in liver or obstruction of bile
ducts within liver eg. viral/alcoholic
hepatitis, drugs, biliary cirrhosis,
sclerosing cholangitis
 Cholestatic Disease
• Alkaline Phosphatase (ALP)
‰>80% in liver and bone
‰Component of cells lining bile ducts
‰↑ ALP synthesis by liver in cholestasis
‰ALP >3-5X: cholestatic disease
‰doesn’t differentiate intra/extrahepatic
‰t½ = 7d ↑ after several days
Sources of Alkaline Phosphatase
• Liver
• Bone
• Small intestines
• Placenta/Pregnancy
• Regan isoenzyme (lung
teratoma)
 Causes of Elevated ALP
™Pregnancy ™Primary biliary
™Pancreatic cirrhosis
Cancer ™Cholestasis
™Sarcoid ™Hypernephroma
™Amyloid
™Hyperthyroid
 Primary Biliary Cirrhosis
• Elevated ALP levels
• Elevated bilirubin
• Mildly elevated transaminases
• + Antimitochondrial antibodies
• + Antinuclear antibodies (ANA)
 Cholestatic Disease
γ-Glutamyl Transpeptidase (GGT)
‰ Enzyme produced in bile ducts
sensitive
‰ Not specific: inducible in other
diseases/drugs.
‰ Used to confirm liver source of ↑ ALP
‰↑’s with alcohol ingestion
‰not specific use when AST:ALT >2:1
 Elevated Lactate Dehydrogenase

(Normal 50-150)
• Myocardial infaction
• Pneumocystis Pneumonia (yeast
like fungus)
• Hemolytic Anemia
• Pancreatitis
• Mononucleosis (Epstein Barr virus)
 Clinical significance of hepatic
enzuyme
Clinical significance Specificity
AST Its increase explained Skelatal, cardiac,
(s- within muscular and hepatic, good tool
hepatic disorders within in cows, horses
GOT)
the package of clinical &
lab. findings
ALT Injury of liver cells in Human, cannine
human, cannine

ALP within the package of Bone, intestinal

clinical & lab. Findings, mm, liver and
especially for bile duct placenta
Argina within the package of Non specific, good
se clinical & lab. findings in hepatic cell
necrosis
 VI- Liver biopsy

• Technique.
• Instrumentation.
• Animal preparation.
• Uses:
• Fatty liver cirrhosis.
 Stepwise approach
• Confirm the abnormal liver test result
actually reflects liver disease.
- rule out non-hepatic factors
- confirm each abnormal test with another
test
• eg. ↑ AST with ↑ ALT
• ↑ ALP with ↑ GGT
• ↑ albumin with ↑ INR
 Report of LFT
Test Unit result Normal
T. protein mg/dl 65-85
Albumin mg/dl 35-45
Globulin mg/dl 30-45
Total mg/dl 0-2.5
Bilirubin
Direct mg/dl 0-0.3
Bilirubin
Indirect mg/dl 0-1.5
Bilrubin
 Report of LFT
Test unit result Normal

AST U/l Up to 100

ALT U/l Up to 80

GGT U/l Up to 25

ALP U/l Up to 120

Prothrombin sec 12-14

time