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Comparative study of serum 5' nucleotidase,alkaline phosphatase ,alt,ast & bilirubin in hepatobiliary disease
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Comparative study of serum 5' nucleotidase,alkaline phosphatase ,alt,ast & bilirubin in hepatobiliary disease

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  • 1. Int J Cur Biomed Phar Res. 2011; 1(3): 93 -97 Contents lists available at CurrentSciDirect Publications International Journal of Current Biomedical and Pharmaceutical Research CurrentSciDirect Journal homepage: www.currentscidirect.com PublicationOriginal articleComparative Study of Serum 5 Nucleotidase,Alkaline Phosphatase ,Aminotransferases and Bilirubin in Hepatpbilrary DiseasesDr.Anil BattaAssociate Professor, Baba Farid Univ. of Health Sciences, Faridkot, India.ARTICLE INFO ABSTRACTKeywords:Cholecystitis Differential diagnosis of liver and biliary tract depends a lot on study of various enzymes assay.Hepatitis The development of serum enzymology has improved a lot the ability to diagnose & to monitorMalignancy the clinical course of patients & treatment of patients with Symptomatic & asymptomaticAlcoholc cirrhosis hepatobiliary diseases.For this a huge repository of enzyme assays is now available. The application of serum enzymes to the diagnosis of alcoholic hepatitis was introduced a way back in 1960s with the demonstrated usefulness of Alkaline Phosphatase assay in differential diagnosis of jaundice. A few years after that Ladue, Wroblewski & karmen showed that higher level of AST & ALT were characterized of some forms of hepatic disease led to an explosive increase of interest in serum enzyme assay as a diagnostic tool. Serum enzymology has proved to be a particular welcome addition to clinical hepatology. Of the more than 100 tests of hepatic function that have been devised none by itself has been reliable in the distinction of hepatobiliary diseases. The addition of selected enzyme tests to the roster of other procedures has enhanced the precision diagnosis. Amino transferases value is often useful in monitoring the course of acute & chronic parenchymal liver disease, though they are misleading certain circumstances (Wrobewski & La Dua, 1985). ALT is relatively specific for hepatobiliary disease.ALP activity may be increased in many diseases not associated with hepatic disease like bone, pregnancy, intestine, kidney diseases. Enzyme 5 NT was selected to observe its impact as a key enzyme for diagnosis of Hepatobiliary diseases. c Copyright 2011. CurrentSciDirect Publications. IJCBPR - All rights reserved.1. Introduction found in patients with ALD. Heavy drinking for as little as a fewdays can lead to “fatty” liver, if drinking continues, in some patients thisThe liver is one of the largest and most complex organs in the body. inflammation eventually leads to alcoholic cirrhosis, in whichIt stores vital energy and nutrients, manufactures proteins and healthy liver cells are replaced by scar tissue (fibrosis), leaving theenzymes necessary for good health, protects the body from liver unable to perform its vital functions. This finding has lead thedisease, and breaks down (or metabolizes) and helps remove researchers to single out an enzyme & metabolite which is specificharmful toxins, like alcohol, from the body. Because the liver is the & undoubtedly an early index of hepatobiliary disease [1-5].chief organ responsible for metabolizing alcohol, it is especiallyvulnerable to hepatobiliary diseases related injury. Even as few as Secondary liver cancer is a cancer that did not originate in thethree drinks at one time may have toxic effects on the liver when liver, but originated in some other part of the body and eventuallycombined with certain over–the–counter medications, such as spread to the liver. It is important to realize, however, that eventhose containing acetaminophen. This issue of Alcohol Alert though the tumor spread to the liver, secondary liver cancer willexamines the diagnosis and treatment of alcoholic liver disease behave according to its origin. Prostate cancer involving the liver(ALD), a serious and potentially fatal consequence of drinking will behave like prostate cancer. Secondary liver cancer is alwaysalcohol. Another disorder, hepatitis C, also featured here, often is the result of primary cancer elsewhere in the body. Primary cancer is caused by the bodys cells continuously dividing and growing * Corresponding Author : Dr.Anil Batta into a lump called a tumor. If the cancer cells that make up this Associate Professor Baba Farid Univ. of Health Sciences tumor escape via the bloodstream and settle in the liver, it becomes Faridkot India secondary liver cancer [6-9]. E mail: akbattafarid@yahoo.co.in c Copyright 2011. CurrentSciDirect Publications. IJCBPR - All rights reserved.
  • 2. Anil Batta / Int J Cur Biomed Phar Res. 2011; 1(3): 93 -97 94 There are several primary cancer sites from which metastatic It may increase only up to 5 fold of the normal activities. Up to 10tumors in the liver may originate, including lung, kidney, breast, fold increase is seen in carcinoma of the liver. In both cirrhosis andstomach and colon. Even though there are many possible origins, carcinoma activity of AST is found to be higher than the ALT. Evensecondary liver cancer results from the spread of primary though the activities of both AST and ALT are elevated in the serumcolorectal cancer up to 50 percent of the time. In some cases, the of the patients with liver diseases, ALT is more liver specificorigin of secondary liver cancer cannot be found, even with enzyme as increased ALT activity in serum is hardly seen in tissuesmedical testing. The reason is that the primary tumor may be too other than liver cell damage [11-14].small to detect and is not causing any symptoms. This is Clinical Significanceoccasionally referred to as unknown primary cancer. Secondary Serum 5NT activity is generally elevated in hepatobiliaryliver cancer has many possible origins because of the important diseases, especially with intrahepatic obstruction, but, unlikefunctions the liver performs. All of the bodys blood passes serum alkaline phosphatase, serum 5NT activity is not increasedthrough the liver, leading to early metastasis Because the liver in infancy, childhood, pregnancy, or osteoblastic disorders. It canfilters the bodys blood, it is often the first site of metastatic spread. help confirm the hepatic origin of an elevated ALP. GeneticAs a result, prognosis for secondary liver cancer does not always deficiency of erythrocyte pyrimidine 5NT activity is a commonmean the cancer cells have spread to other organs of the body, cause of hereditary non-spherocytic hemolytic anemia. Acquiredmaking early discovery is even more important.. In malignancy the deficiency of erythrocyte pyrimidine 5NT activity occurs incancer cells detection in ascitic fluid becomes significant. So there patients with beta-thalassemia and lead poisoning. 5NT activity isis parenchymal damage raising the AST/ALT. Again both 5NT and low in circulating monocytes, increases markedly upon theirALP rise due to proximity of the lesion and cholestasis. Having a differentiation to tissue macrophages, and subsequentlyliver metastasis is the most important indicator of disease diminishes during macrophage activation. Lymphocyte ecto-5NTprogression. Monitoring the elevation of ALP levels at each activity, a plasma membrane marker of cell maturation, ispatients follow-up visit may be economically used as an indicator generally low in immunodeficiency states, and undergoesof subsequent liver metastasis. Furthermore, a change in ALP characteristic changes in patients with certain lymphomas andlevels of greater than 120 U/L over a period of 4 to 6 months may leukemias. In cancer patients, elevated serum 5NT activity doesbe indicative of advanced disease progression, which warrants a not always indicate hepatobiliary involvement; in some cases,more aggressive treatment or a change in regimen. ALP is a simple, 5NT may be released into serum from the primary tumor or locallow cost, relatively sensitive screening tool for detecting liver metastases [3-5].metastasis. Future studies aiming at better defining the role of ALPin colon cancer is significant. Here again 5NT has an edge due to Alkaline phosphatases are present in almost all tissues of theits relative specificity and sensitivity [10-15]. body. They are membrane bound and are zinc containing metalloenzymes. Alkaline phosphatases are a family of Transaminases are present in most of the tissues of the body. isoenzymes. They hydrolyze a variety of organic phosphate estersThey catalyze the inter conversions of the amino acids and 2- transferring phosphate groups from a donor substrate to anoxacids by transfer of amino groups.Transaminases are specific acceptor containing a hydroxyl group. The isoforms derived fromfor the amino acid from which the amino group has to be the tissue non-specific isoenzyme by post translationaltransferred to a keto acid. 2-oxoglutarate and glutamate couple modification include the variants of the enzyme found in the liver,serves as one amino group acceptor and donor pair in all amino bone, kidney and the placenta. Some malignant tumors cantransfer reactions. In both the reactions pyridoxal-5-phosphate produce a placental form of the enzyme called the Regansfunctions as a prosthetic group in the amino transfer reactions. isoenzymes.Normal serum values: AST (SGOT) - 0-41 IU/L and ALT (SGPT) - 0-45 IU/L. In newborns value up to 120 units for AST and 90 units for Physiological bone growth elevates ALP in serum and hence inALT is considered normal. the sera of growing children enzyme activity is 1.5-2.5 times that in normal adult serum. The level of ALP in the serum of women inClinical significance the third trimester of pregnancy is 2-3 times more than that of Liver diseases: Determinations of activities of AST and ALT in normal level. Biliary obstruction due to any cause may elevateserum in patients with liver diseases like viral hepatitis and other ALP level by increasing its synthesis from the hepatocytesforms of liver diseases with necrosis, give high valueseven before adjacent to the biliary canaliculi. This newly synthesized ALPthe appearance of clinical signs and symptoms like jaundice. enters the circulation and elevates the enzyme level in the serum.Activity levels of 20 to 50 fold higher than normal are frequently Elevation of ALP in the serum is more with extra hepaticseen in liver cells damage but it may reach as high as 100 times in obstruction by stones or by carcinoma head of pancreas than insevere damage to cells. Highest serum activities are seen between intrahepatic obstruction. The enzyme level may return to normal7th and 12th days and return to normal levels by the 3rd to 5th on removal of the obstruction. Liver diseases affectingweek. In sevre tissue damage ALTactivity is higher than AST and parenchymal cells like infectious hepatitis show only moderatethe ALT:AST ratio becomes ≥ 1 (normally <1). Some increase in elevation or normal serum ALP levels. Bone diseases withthe activities of ALT and AST are seen in extra hepatic cholestasis. increased osteoblastic activity shows increased ALP level in theIn cirrhosis the level of activities vary with the severity of the serum. Serum ALP activity may be increased in many diseases notdisease.
  • 3. Anil Batta / Int J Cur Biomed Phar Res. 2011; 1(3): 93 -9795associated with liver like bone diseases, pregnancy, normal growth years. Out of these 40 served as control taking good diet, withoutand occasionally the presence of malignancy not involving either HO smoking & drinking & taking healthy diet. While 60 patients ofbone or liver. For this reason the tissue, the organ of tissues of origin different diseases hepatobiliary diseases on the bases of clinicalmust be identified. Serum hepatic ALP is usually increased in the findings were selected as follows:bile duct obstruction but this increased enzyme reflects more of 1) Group 1) 21 patients suffering from Cholecystitis withenzyme synthesis rather than decreased biliary excretions or cholelithiasis.leakage from damaged cells. On the other hand 5Nucleotidase 2) Group 2) 19 patents of hepatic malignancy(5NT) is increased in hepatobiliary diseases doesnt usually rise in 3) Group 3) 33 Infective Hepatitis casesbone diseases. 4) Group4) 27 cases suffered from alcoholic liver disease (ALD). The serum activity of 5NT is increased in cholestasis & its major Jaundice : 27 cases showed as a clinical finding.clinical value is that it may be of help in identifying the source of 2.1 Collection of Serumelevated serum ALP activity. About 20 ml. of blood was collected by venepuncture using all But we are concerned about a marker which is significant in all aseptic method & allowed to clot at room temperature. It washepatobiliary diseases. In this work we explored the significance of centrifuged at 3000 rpm for 10 minutes to separate serum.5NT,ALP,AST,ALT and serum bilirubin. 5NT is the enzyme which is Following methods were adopted:increased in hepatobiliary diseases. It is phosphatase which isinvolved in release of inorganic phosphate only from the nucleoside Estimation of following enzymes was done by following5 –phosphate, e.g. it acts on adenosine 5-monophosphate (AMP) to colorimetric methods:form adenosine and release inorganic phosphate. It is ubiquitously 1. Serum 5—Nucleotidase—Method of Campbell 1962.present in all the tissues and is localized in the plasma membrane of 2. Serum Alkaline Phosphatase –Method of kind & King 1954the cells in which it is present. Serum 5NT activity is generally using aminoantipyrine.elevated in hepatobiliary diseases, especially with intrahepatic 3. Serum ALT | AST by method of Reitman & Frankel, 1957.obstruction. But, unlike serum alkaline phosphatase, serum 5NT 4. Serum bilirubin by method of Malloy & Evelyn, 1937.activity is not increased in infancy, childhood, pregnancy, or However all the results were counterchecked so as to removeosteoblastic disorders. It can help confirm the hepatic origin of an problem of any discrepancy. These were done by fully automatedelevated ALP [15-20]. device. 3. Results2. Materials & Methods Are expressed (Table-1& Figures) as Mean ±SEM. Stastical Keeping in mind the Helsinki guidelines all patients were asked significance was determined by students test for unpaired data.for permission. All patients attending the OPD & Indoor of Rajindra The value significance was evaluated with p values. The differencesHospital, Patiala were selected. Study was conducted on 100 were considered significant at p<0.001.patients of different hepatobiliary disease .Age group was 20 to 60Table 1. Statistical analysis of serum levels in study Group Group and Number of Total Bilirubin AST IU/L ALT IU/L ALP KAU/L 5NT IU/L Total Albumin Diagnosis patients mg% Mean Mean Mean Mean Protein G% G% studied Mean (Range) Range Range Range Range Mean Range Mean Range I. Cholecystitis with Cholecystitis 2.27±4.43 52.9±5.91 50.45±12.96 276±34.88 120.9±19.1 6.34±1.01 2.3±0.09 cholelithiasis 21 (0.4--19) (22-48) (33-64) (147-287) (46-187) (6.2-6.7) (1.8-2.5) 2.hepatic Hepatic 5.95±6.55 66.88±7.16 69.34±10.98 287±26.18 52.28±13.45 5.50±0.19 1.23±0.65 malignancy malignancy (0.6—22) (41-97) (45-76) (159-323) (28-121) (5-6.01) (1.32-0.98) 19 3.Infective Viral hepatitis 8.46±4.5 53.87±13.20 65.87±9.87 76.90±12.98 59.34±2.98 7.23±1.98 1.87±0.43 hepatitis 33 (4-16) (43-88) (49-88) (65-87) (50-76) (7.8-5.6) (1.76-2.09) 4.Alcoholic Alcohol (2.54±1.3) 57.53±7.32 51.12±7.8 198±69.5 50.28±13.76 6.34±2.56 0.98±0.02 liver disease liver disease (42-65) (38-52) (198-298) (34-98) (5.9-6.8) (0.87-0.99) 27 Control 40 19.98±2.87 20.2±3.5 130±25.12 12.9±2..12 7.67±0.17 2.34±0.87 (20-24) 16-28 (121-145) (18-20) (7.32) (0.17-0.21) Hepatobiliary 100 4.66±5.77 62.66±25.87 67.45±8.8 (198±287) 49.09±87.54 6.12±2.5 1.12 diseases (0.6-22) (46-165) (59-121) (43-97) (6.32) (1.87)
  • 4. Anil Batta / Int J Cur Biomed Phar Res. 2011; 1(3): 93 -97 96Figure 1. more helpful in ALD. Raised bilirubin is insignificant when compared with Serum ALT| AST & 5NT in cirrhosis or chronic ALD. Contrary to other workers we found 5NT is markedly significant than ALP. There is markedly low level of serum proteins as they are produced by liver as it is major synthesizer of proteins. Because of this there is low blood volume which causes hypotension due to hemodynamic disturbance. In Cholecystitis with cholelithiasis real time Ultrasound allowed distinction between extra hepatic causes with dilated bile ducts within the liver from intrahepatic cause. ALT|AST were markedly raised but insignificant. ALP is significantly increased than 5NT as bile salts is increased in hepatocytes & solubilize the plasma membrane.5NT is significantly raised in extra & intra hepatic cholestasis. Hepatic malignancy is fourth big cause of liver cancer & is third for mortality (Parkin 2005). In India, hepatitis B is major risk factor in third world countries. More than 80% are due to background of cirrhosis which causes angiogenesis & is characteristic sinusoidal capiliarization.Figure 2. Increased expression of enzymes in endothelial cells along with deposition of extra cellular matrix & micro vessel formation there Liver is the most common site of distant metastasis due to unique vascular architecture liver allows metastasis as it is a storehouse of nutrients, oxygen through various mechanism like angiogenesis. According to Barcelona clinical liver classification carcinomas are grade c,tumour, stage is advanced, there are large multiple nodules with vascular invasion & extra hepatic secondaries. Total bilirubin & aminotransferases levels were not significantly raised. 5 NT levels were raised significantly due to angiogenesis, total proteins & serum albumin level were significantly decreased. 5. Conclusion By all practical purposes liver biopsy is the best test to study4. Discussion chronic liver disease as part of management. This explains severity of liver damage & fibrosis (Bravo A Aet al, 2001).but this is hurting, Patients were scanned of all 4 groups. There is an intra complicated, costly, invasive & full of error.Mortality rate amongcomparison between patients with Alcoholic Liver Disease & in them is 0.3%.cholecystitis. As a result of those problems & reluctances of patients to go for it The patients with ALD & cirrhosis (Group 4) compared with biochemical biomarkers carry an upper hand to precisely predictpatients of hepatic malignancy (Group 2) show loss of protein the severity of liver disease (Carl.A lehmann, 2005) So this warrantscausing significant loss of weight. This is explained due to reduced a cautious approach in interpreting results of the tests. But if takenadipose tissue .In viral Hepatitis (Group 3) hyperbilirubinemia is together the data provides reason that 5NT is so widely raised but itcommon symptom like in many other groups of patients but it is not confined to be a marker of ethanol consumption, its veryseparated hepatic malignancy (Group 3) from other Groups. much useful in deciding the cause of raised ALP in liver either fromSeverity of rise in ALT is more significant than serum AST in this bone/liver, very much useful in differentiation of mechanical biliarygroup. 5 NT & ALP were also somewhat significant (p<0.01).Ratio obstruction & intra hepatic cholestasis represents one of the classicof AST/ALT was lower than in normal individuals. In acute hepatitis diagnostic challenge in clinical medicine. Most of clinicians considerAST & ALT were more significant than 5NT.It was also observed that 5 NT as a significant indicator in obstructive choleststasisit was more significant in hepatitis B & hepatitis C as compared to conditions: However the rise in serum 5NT increases several daysbiliary canaliculi enzymes. Toxicity of alcohol is common in Indians after obstruction of biliary ductile system & may lag behind the3.5% of global burden is due to this (Racial & Ethnic 2002) Ethanol elevations in serum ALP.induced endotoxaemia & acetaldehyde which is produced byoxidation of ethanol is more often a cause of liver damage. This is So ultimately based on our study we conclude 5NT is adue to free radical or sometimes by not. Conjugated levels of significant, non-invasive biochemical tool in the differentialbilirubin are raised much more in ALD. Deficiency of pyidoxal diagnosis of all hepatobiliary diseases when it is juxtaposed withphosphate is common in ALD..Ratio of AST/ALT is more in heavy ALP, AST, ALT and bilirubin level.drinkers. It is a good marker of ALD. Level of 5NT with ALP was
  • 5. Anil Batta / Int J Cur Biomed Phar Res. 2011; 1(3): 93 -97977. References[1] Gutman AB: Serum alkaline phosphatase activity in disease of the skeletal [12] McMaster Y, Tennant R, Clubb JS, Neale FC, Posen S: The mechanism of the and hepatobiliary systems. Am J Med. 1959;27:875-901. elevation of serum alkaline phosphatase in pregnancy. J Obstet Gynaecol Br[2] Posen S: Alkaline phosphatase. Ann Intern Med. 1967;67:183- 203. Emp. 1964; 71:735-739.[3] Roberts WM: Variations in the phosphatase activity in the blood in disease. [13] Philip JR, Grodson GM, Carbone JV: Mercaptic conjugation in the uptake and Br J Exp Pathol. 1930;11:90-95. secretion of sulfobromophthalein Am J Physiol. 1961;200:545-547.[4] Kaplan MM: Alkaline phosphatase. Gastroenterology. 1972; 62: 452-468. [14] Klaassen CHL: Age and serum alkaline phosphatase Lancet. 1966; 2:1361.[5] Posen S, Neale FC, Birkett DJ, Brudenell J: Intestinal alkaline phosphatase in [15] Heino AF, Jokipii SG: Serum alkaline phosphatase levels in the aged. Ann Med human serum. Am J Clin Pathol. 1967; 48:81-86. Intern Fenn. 1962;51:105-109.[6] Robinson JC, Goldsmith LAi Genetically determined variants of serum [16] Deren JJ, Williams LA, Muench H, Chalmers T, Zamcheck N: Comparative alkaline phosphatase: A review. Vox Sang. 1967; 13:289-307. study of four methods of determining alkaline phosphatase. N Engl J Med. 1964; 270:1277-1283.[7] Clubb JS, Neale FC, Posen S: The,behavior of infused human placental alkaline phosphatase in human subjects. J Lab Clin Med. 1965;66:493- 507. [17] Long CH, Ullrey DE, Miller ER: Serum alkaline phosphatase in the postnatal pig and effect of serum Storage on enzyme activity. Proc Soc. Exp Biol Med.[8] Clarke LC, Beck E: Plasma "alkaline" phosphatase activity. I. Normative data 1965;119:412-414. for growing children. J Pediatr. 1950;36:335-341. [18] Wolf PL: Clinical significance of an increased or decreased serum alkaline[9] Kattwinkel J, Taussig LM, Statland BE, Verter JI: The effects of age on alkaline phosphatase level. Arch Pathol Lab Med. 1978;102:497-501. phosphatase and other serologic liver function tests in normal subjects and patients with cystic fibrosis. J Pediatr. 1973;82:234-242. [19] Kaplan MM, Rogers L: Separation of human serum alkaline phosphatase isoenzymes by polyacrylamide gel electrophoresis. Lancet. 1969;2:1029-[10] Salz JL, Daum F, Cohen MI: Serum alkaline phosphatase activity during 1031. adolescence J Pediatr .1973;82:536-537. [20] Brensilver HL, Kaplan MM: Significance of elevated liver alkaline[11] Birkett DJ, Done J, Neale FC, Posen S: Serum alkaline phosphatase in phosphatase in serum. Gastroenterology. 1975;68:1556 - 1562. pregnancy: An immunologic study. Br Med J 1966;1:1210-1212. c Copyright 2011. CurrentSciDirect Publications. IJCBPR - All rights reserved.