Laboratory of

Liver disease
FUNCTIONS OF THE LIVER:
The various functions of the liver are carried out by the hepatocytes.
1.BILE :The liver produces and excretes bile required for dissolving
fats.
2. CARBOHYDRATE:The liver performs several roles in carbohydrate
metabolism:
Gluconeogenesis (the formation of glucose from certain amino acids
Glycogenolysis (the formation of glucose from glycogen) --- process of
breaking down stored glucose.
Glycogenesis (the formation of glycogen from glucose) To put it into
storage form for when body need it.
3.DETOXICATION :The liver breaks down toxic substances and most
medicinal products (drug/toxin detoxification).
The liver converts ammonia (product of protein breakdown) to
urea which is excreted by the kidneys as part of urine.
4.HORMONES:The breakdown of insulin and other hormones.
5.LIPID:The liver also performs several roles in lipid (fat)
metabolism:
Cholesterol synthesis .
6. COAGULATION :The liver produces coagulation factors :
I(fibrinogen), II (prothrombin), V, VII, IX, X and XI, as well as protein
C, protein S and anti thrombin. -----Test : PT
7. HEMOGLOBIN :The liver breaks down hemoglobin, creating
metabolites that are added to bile as pigment.

8.STORE:The liver stores a multitude of substances, including

glucose in the form of glycogen, vitamin B12, iron, and copper.

9.IN THE FIRST TRIMESTER FETUS, the liver is the main site of red
blood cell production. By the 32nd week of gestation, the bone
marrow has almost completely taken over that task.

10. IMMUNOLOGI: The liver is responsible for immunological

effects- the reticular endothelial system of the liver contains many
immunologically active cells.
What are liver function tests?
Liver function test (LFT)
- a blood test that gives an indication of whether the liver is
functioning properly.
- detect inflammation and damage to the liver

Useful to see if there is

1. active damage in the liver cells
2. sluggish bile flow (cholestasis).
3. function synthetic of the liver

Diagnosis of liver disease depends on

1. patient history
2. physical examination
3. laboratory testing, biopsy and sometimes imaging studies
such as ultrasound scans.
The most indication of LFT
- have / suspect liver disease
- taking a medication that can harm the liver
- have symptoms of liver or bile system disease .
( abdominal pain, nausea, vomiting or yellow skin )
- monitor the activity and severity of liver disorders.
- drink alcohol excessively
- medical check up
LIVER FUNCTION TESTS
1.Integrity liver cells test
Enzyme liver consist in cytoplasm and mitochondria.
a . At increasing permeability cells wall enzyme cytoplasm will bee increase (
AST, ALT, LDH 5)
b. If damage involve mitochondria enzyme will bee increase too (
AST, GLDH).
The activity of AST in the serum is less than that of ALT because only 20 % of
AST is localized in cytoplasm and 80 % is in the mitochondria.
Mitochondria enz only appear in the blood following complete cell destruction
and necrosis leading to an increase in enzyme that are found only in
mitochondria such as GLDH and a further rise in AST .
If ALT and AST are found together in elevated amounts in the
blood, liver damage is most likely present.
AST then increase above ALT/ complete cell
destruction
The ratio AST : ALT : the Ritis ratio , rises above 1
AST = Aspartate Aminotransferase = SGOT
AST enzyme is also found in muscles and many other tissues
besides the liver.

ALT = Alanine Aminotransferase = SGPT

ALT is almost exclusively found in the liver.

LDH = Lactic Dehidrogenase

GLDH = Glutamate Dehidrogenase
2.Test for cholestases :
Cholestatic enzymes ( Alkali Phosphatase/ ALP, GGT, 5 NT)
activities increase ( especially in extra hepatic blockage), but only
mild increase in hepato cellular destruction .
The basic test may indicate cholestasis if the GGT is raised more
than ALT /SGPT
The most sensitive for cholestasis : ALP but less specific , because
ALP elevation also seen in normal childhood, pregnancy and bone
disease.
GGT = Gamma Glutamyl Transfpeptidase
5 NT = 5 Nucleotidase
3.Syntetic function tests
a) Albumin concentrations :
Impaired of synthesis function ----hypo albuminemia; more
prominent in chronic than in acute phase. This test is less
sensitive but good for make prognosis
b) Protein Electrophoresis (Protein separate into fragment
Alfa 1 glob, Alfa 2 Glob, Beta glob, Gamma glob).
Protein profiles are useful as additional information to make
differential diagnosis eq polyclonal gammopathy type.
c) Cholinesterase enzyme activity
In hepatocellular destruction (chronic hepatitis , liver cirrhosis and
drug related liver disease, organophosphate intoxication ): serum
or plasma cholinesterase is reduced .
Cholinesterase enzyme activity good for estimate prognosis.
d) Coagulation factor : Prothrombin time.
4.Excretory function tests.
a. Bilirubin concentration ( total, direct, indirect) . Urinary bilirubin,
urinary and fecal urobilinogen, urinary urobilin and fecal sterkobilin.
b. Gamma GT & Alkali Phosphatase
c. Ichterus index : (Now is rarely use )
It is an absolute test, it only estimates serum bilirubin concentration
by comparing serum color to potassium bichromat solution color.

5.Detoxifying function test

Blood amonia level
amonia absorb in gut ---- chance to ureum by liver cells, ---- excreted by
kidney.
In Hepatic failure blood amonia level increases and could cause hepatic
coma.
6.Tests for etiologic factors :
Auto antibodies ;
AMA /Anti Mitochondrial Antibody ---- in primary biliary cirrhosis
SMA /Smooth Muscle Antibody ---------- in chronic active hepatitis,
ANA /Anti Nuclear Antibody -------------- in lupoid , type chronic active
hepatitis.
Sero marker Virus hepatitis
Hepatitis A : anti HAV IgM
Hepatitis B : HBsAg, HBeAg, anti HBs, antiHBe
anti HBc (IgG/IgM), HBV DNA
Hepatitis C : anti HCV (total, IgM) HCV RNA
Hepatitis D : HDAg, anti HD(Ig G, IgM)
Hepatitis E : anti VHE (IgG, IgM)
7.Coagulation test
1.PT (Prothrombin Time ):
Test for production of coagulation
factors
2.INR (international normalized ratio) :
Can monitor how much medicine (commonly warfarin) to
take. Increased levels of INR means blood is taking more
time than usual to clot.
The INR increases only if the liver is so damaged that
synthesis of vitamin K-dependent coagulation factors has
been impaired;.
It is very important to normalize the INR before operating
on people with liver problems
 LABORATORY TEST
1.VIRAL LIVER DISEASE
1.1 .Acute Hepatitis A
- Hepatitis A spreads through contaminated food or water.
- Cytoplasmic enzyme much higher than mitochondrial enzyme
so that the Ritis ratio is about 0,4 (ALT>AST)
- In practice acute hepatitis A is diagnosed by detection of
specific human anti HAV Ig M antibodies in serum or plasma .
Anti HAV IgM increase : in the start of disease

In protracted disease the anti HAV IgM persist over longer period
and the fall is slower. (still detectable after 8 10 weeks )
Treatment of Hepatitis A
Hepatitis A usually heals spontaneously with no complications
Hepatitis A vaccine is highly effective combined with immune globulin for maximum
protection
 1.2 Acute hepatitis B
Hep B virus contains several antigens that important in diagnosis .
There are called
HBs Ag (s = surface),
HBc Ag (c = core) and
HBeAg (e= epsilon -- is a marker of infectivity) .
All antigens induce formation of the corresponding antibodies.
The transaminases may reach levels more than 50 times the
normal and ALT being cytoplasmic enz, rises higher than AST and
the Ritis (AST/ALT) ratio is about 0,6.
LDH rises high, GLDH, ALP and GGT only slight increase.
80 85 % patient with infectious HBV will make antibody :
Anti HBs
Anti HBc
Anti HBe
5- 10 % of cases of acute hepatitis B, HBsAg, HBeAg and HBV
DNA are all undetectable at the time the diagnosis can only
make with detection of antibodies.
Anti HBc early appears in serum and remain positive for years
and is detectable in acute and chronic hepatitis B even after
resolution of the infection. The last of antibodies is anti HBs
which becomes detectable after about six months.
Anti bodies titer can a signifies immunity if anti HBs titer is >
100 IU/L .
1.3 Chronic Hepatitis B
Chronic Hepatitis B is present if HBsAg and HBV DNA
remain detectable for more than 6 months.
According histological criteria chronic hepatitis divided 2
cat :
Chronic active and Chronic persistent hepatitis.

More recent classification is based on the level of viral

replication and the degree of liver cell damage, the
crucial indication being anti HBe and the transaminase.
1.3.1 Chronic persistent hepatitis B :
* Slightly raise AST, ALT, GGT ( 2 4 times normal)
* de Ritis ratio < 1
1.3.2 Moderate Active chronic hepatitis B :
* Most lab tests like Chronic persistent , only GGT and
immuno globulins greater rise.
1.3.3. Highly Active Chronic Hepatitis B:
* Enzyme raise up to 10 times
* de Ritis ratio > 1
* Bilirubin , GLDH greatly increase
* Albumin decrease

Anti HBs (+), anti HBc (+) : previous Hepatitis B

Anti HBc IgM, HBsAg (-) : Hepatitis has resolved
HBeAg (+) : High infectivity
HBeAg (-) : Clinically in active
1.4. Chronic Hepatitis C
- Hepatitis C often runs an unremarkable or even silent . ---Very dangerous become
chronic 75 85 % of cases .--- risk for cirrhosis and hepatoma .
Lab : Transaminases 10 15 times normal and while transformation to chronic form they
moderately raised about 3 5 fold.
Typicaly chr hep C transaminase very markedly between normal and very increase over
period of months.
ALP and GGT usually some what higher than in other form of viral hepatitis.
ANA or SMA often present in chronic Hep C
Diag is made using serological and molecular biological test can be detected in serum
three to six months after infection.
Reagent must have sensitivity more than 90 %) --- neg test not absolutely exclude hepatitis
C completely ( windows period).

STEP OF EXAMINATION :
Anti HCV ( + ) ---------- HCV Immunblot / HCV RNA (+) ---- Viral load.

HCV RNA (+) after 6 days infection.

HCV RNA ( - ) ------- disease has resolved
HCV RNA ( + ) Anti HCV ( + ) ------- Chronic Hepatitis C
Genotype hepatitis C : 6 sub type ----- depend on geographical distribution.
1.5. Hepatitis D
Occur coincidental Hepatitis B.
Patient with both hep B +D frequently have particularly severe disease
Co Infection : infection simultaneous HBV and HDV
Super infection :HDV infection occurs in some one already infected with
HBV.
In Acute phase anti HDV Ig M become positive after 4 5 weeks . Titer
higher in super infection than co infection.
1.6 Hepatitis E
Transmitted enterally like hepatitis A ( the virus ingested orally and
excreted in the stool .
AST and ALT increase ALT > AST
In uncomplicated case enzyme activities return normal in 4 6 weeks.
Diagnosis : detection of anti HEV Ig M.
Confirm diagnosis : detection of HEV RNA using PCR
2. Prognosis And Monitoring therapy chronic Hepatitis.
Chronic hepatitis ------ transformation to liver cirrhosis or liver carcinoma are
most complications
For monitoring interferon therapy :
ALT and AST , Blood Count every 14 days in the first two months, then every four
to six weeks.
TSH every three month because possibly thyroid dysfunction.
PCR for virus detection repeated every 3 to 6 months
Active chronic hepatitis :
Transferase increase
Protein synthesis reduced
AFP increase
If progression to liver cirrhosis GLDH increase,
If Carcinoma occur : GLDH and AFP rises very high.
3.Alkohol related liver disease :
Excessive alcohol consumption acts as an endogenous toxin to the liver ---
necrosis + inflammation -----chronic.
Most important : GGT increase greater extent than aminotransferase , ALP
normal. AST increase more than ALT ( de Rittis Ratio > 2 )
MCV >95 fL are characteristic for alcohol related damage.
GLDH, IgA -- increase
CHE decrease

4. Auto immune liver disease :

Characterized by disturbed immune tolerance to liver and biliary tissue : AIH, PSC
(primary sclerosing cholangitis, PBC ( primary Biliary cirrosis).
First sign : Increase aminotransferase without obvious cause.
The first evidence if often raised immunoglobulins , gamma globulin 1,5 times
above normal due to increase in IgG --- usually PSC and PBC small increase IgM.
5.Metabolic liver diseases
Inherited liver disease : Cystic fibrosis (mucovicidosis)
Acute and chronic porphyria
Disorder metab bilirubin ( Crifler Najjar Syn, Gilbert
Syndr Dubin Johnson Syn , Rotor Syndr )
Hemochromatosis
Wilson disease
1 anti tripsin deficiency
Most important is demonstration of the enzyme and gene defect.
5.1 .Haemochromatosis
Deposit Fe in the liver
Transaminase, GGT, GLDH are midlly elevated
Cholinesterase clotting fact and export prot : normal
BSP : raised
SI : Raise
5.2 Wilson disease
Disorders of excretion and transport of cooper lead to accumulation of this
metal in various organs, liver and brain are mist severely affected ----liver cell
damage with clinical features of chronic hepatitis, sometimes with fulminant
course--- end stage cirrhosis
Diag : Serum caerulo plasmin low
Urine cooper excretion extremely high
Serum cooper low until liver not capable storage the cooper.
Most typical this disease : high content cooper of the liver ( measure
quantitative by atomic absorption in biopsi material ( 10 50 times normal )
5.3 1 Antitrypsin Deficiency
Genetically formation of an abnormal , non secretable variant of 1 antitrypsin
leads to accumulation this protein in hepatocytes. ----result damage to the liver
( simple disorder until cirrhosis.
Diag : show the serum concentration of 1 antitrypsin reduced.
6. Toxic liver diseases
Because s uncommon disease for this reason frequently only consider at a lat
stage in diagnostic procedures.
Noxious agent : chemical ( organic solvent, nitro compounds, hallogenated
hydrocarbons, phosphate esters , metal and their compounds.
These can gain entry the body enter from environmental or in the work place .
Details anamnesis very importance.
Effect to the liver may range from simple to severe disturbances . Diag difficult.
6.1. Organic compounds.
Poisoning with halogenated hydrocarbon compounds ( eq carbon tetrachlroride,
chloroform, vinyl chloride) relative high mortality rate.
Extreme reduction in serum cholinesterase activity is indication of intoxication
by phosphate esters---- diag confirmed by detection the substance its self of
catabolic product in serum or urine or stomach contents
6.2 Inorganic compounds.
Poisoning by metals or metals salt to liver damage.
Source very variable : drinking water, food component, metal objects, dust,
chemicals etc.
diag by measurement the metal in urine serum organ tissue or hair.
6.3.Medication
Lab value non specific pattern, mild liver damage.
Suggested drug liver damage : High GGT
Normal GGT with enzyme abnormal
Sudden fall CHE
Marked discrepancy between increase enzyme act
and unremarkable histology.
More severe damage : Hepatitis with high transaminase, GGT, ALP.
Massive damage only with halothane hepatitis
6.4.Mushroom poisoning.
Variable clinically feature : slight to hepatic coma.
If mushroom poisoning is suspected , the stomach content should be examined
for spores.
7.Others causes of liver diseases.
Atypical example of this infection with cytomegalovirus, Herpes symplex ,
Various zoster, EB virus, HIV , Adeno and enterovirus, Ebola virus, TT virus (
transmited enterally and has word wide distribution).
8. Non alkoholic fatty liver (NAFLD) and non alkoholic
steato hepatitis ( NASH).
* Predominantly in OVER WEIGHT PATIENTS WITH I GT AND
HYPER LIPOPROTEINEMIA.
* Slight increase ALT , AST ; de Ritis ratio below 1.
* GGT, ALP, feritin and transferin saturaton slight increase.
* Diag made with aid histologicl examination.
9. Liver cirrhosis .
Any chronic liver disease may progress to cirrhosis because of fibrosis.
Diag can made by histological and damage can be grade using various scoring system.
Lab : slight increase ALT and AST,GLDH, GGT and serum iron. Albumin decrease, Gamma
globulins increase
Hb, leuko and platelet reduced, bilirubin and bile acid increase
clotting fac deficiency, hypokalemia
Cholin esterase decrease, amonia consentration increase--- prog unfavourable.
Best marker : apolipoprotein A1 and propeptide of procollagen tyoe I and III ( P
III- NP )
AFP slight increase , continuous increase suggest development of primary liver cell
carcinoma.
10 . TUMOR OF THE LIVER
BENIGN AND MALIGNANT
Benign : Hemangioma, Adenoma, Liver cyst, Hyperplasia
Malignant ; Hepatocellular Ca, Cholangio Ca, Sarcoma, Various from
malignancy metastases
Diag relies upon imaging techniques and by exclusion of malignant
disease.
Quick PT, APTT and feto protein also determined
Golden key is imaging and histology.
HEPATO CELLULAR CARCINOMA
* One of the most Ca frequent in the word.
* LFT not specific
* golden key : imaging supporting with AFP > 500 ug/L + symptoms
of the liver.
Triple phase helical CT improves the detection of these tumors
* 90 95 % HCC have extremely high AFP ( but AFP have low sensitivity
and low specivicity)
* AFP use for monitoring therapy HCC