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 Case-based large group learning
 Total number of slides in presentation: 22
 3 case scenarios – each presenter will get 4
 min
 Last 10 min is for application and summary
 Total duration of lecture: 40 to 45 min
 Post-test at the end to conclude the chapter:
 Duration 10 min
                                                  2
 At the end of the lecture class the learner
  must be able to:

 List the tests done to assess gastric,
 pancreatic and thyroid function

 Categorise the function tests and their
 importance

 Apply them in clinical situations
                                                3
Assessment of Gastric functions
 Fractional Test Meal (FTM)
  - requires aspiration of gastric contents
  - aspiration: ‘Ryle’s tube’
 Pentagastrin Stimulation Test
  - synthetic ‘peptide’
  - having biological active sequence of gastrin
 Augmented Histamine test
  - Most potent stimulus of gastric secretion
 Serum Gastrin level

                                                   4
Pentagastrin Stimulation Test
 Fasting gastric juice is aspirated by Ryle’s tube
 → ‘Residual juice’
 Gastric juice collected for next one hour is
 collected → ‘Basal secretion’
 Gastric secretion is stimulated by giving
 ‘pentagastrin’
 Dose: 6mg/Kg body weight
 Gastric secretion is collected every 15 min for
 next one hour
                                                      5
Pentagastrin Stimulation Test
 Normal Response by assessment of free and
  total acidity:

       Trait               Men               Women

 Basal Acid Output    0 to 10 mmol/hr    0 to 5.5 mmol/hr

Maximal Acid Output   7 to 45 mmol/hr    5 to 30 mmol/hr
 Peak Acid Output     12 to 60 mmol/hr   8 to 40 mmol/hr




                                                            6
Clinical Application – Gastric functions
            Hyperacidity                          Hypoacidity
Duodenal ulcer                        Gastritis
Gastric cell hyperplasia              Gastric carcinoma
Carcinoid tumours                     Partial gastrectomy
Zollinger-Ellison syndrome            Pernecious anaemia
Multiple Endocrine Neoplasia – Type 1 Chronic iron deficiency anaemia
Basophilic leukemia




                                                                    7
Classification – Thyroid Function Test
 Based on Thyroid Function & Clinical Utility
Group I     Primary function of       Radio-iodine uptake
            thyroid                   T3 – suppression test
                                      TSH – stimulation test
                                      TRH stimulation test
Group II    Measurement of blood      Total T3 and T4 levels
            levels of thyroid         Free T3 and Free T4 levels
            hormones                  Circulating TSH level
                                      Plasma tyrosine level
Group III   Metabolic effects of      Basal Metabolic Rate
            Thyroid hormones          Serum cholesterol level
                                      Serum creatine level
                                      Serum uric acid level
                                      Serum creatine kinase level
Group IV    Immunological tests for   Agar gel diffusion test
            auto-immune disorders     Complement fixation test
                                                                    8
Tests based on primary function of thyroid
 Radioactive ‘Uptake’ studies
 I131 → ‘tracer’ used for thyroid studies
 Normal: 20 to 40%
 TSH – stimulation test
 Basal levels of thyroid hormones is measured
 3 injections of TSH each of 5 USP units is given 8
 hourly
 Failure to produce thyroid hormones → Primary
 hypothyroidism
 Stimulation of gland by production of thyroid
 hormones → secondary hypothyroidism
                                                       9
   A 50 year school teacher came with the
    complaints of coarse speech, dry skin, puffy face,
    non-pitting pedal edema, easy fatigability and
    constipation. Personal history suggested she had
    noticed gaining weight despite decreased appetite
    over the past few months. O/E patient had a
    palpable swelling in front of the neck with brittle
    nails.
   What is your probable diagnosis?
   Suggest the biochemical investigations to confirm
    your diagnosis.
                                                     10
Measurement of blood levels
            of thyroid hormones
Hormone           Method              Reference Range
Total T4          ELISA               5 to 12 µg/dl
Total T3          Chemiluminescence   120 to 190 ng/dl
                  Radioimmunoassay
TSH                                   0.5 to 4.5 mIU/ml
Free T3           Chemiluminescence   0.2 to 0.5 ng/dl
Free T4                               0.7 to 1.8 ng/dl
Plasma Tyrosine                       60 to 70 µ Mol/L




                                                          11
   A 49 year old female came to the medical OPD
    with complaints of intolerance to heat, loss of
    weight in spite of good appetite and excessive
    sweating. She also complained of excessive hair
    loss. O/E patient has protruding eyes and
    tremors of hands.

   What is your probable diagnosis?
   Suggest the biochemical investigations to confirm
    your diagnosis.


                                                      12
Clinical Application of
           Thyroid Hormone Measurement
Disorder          Causes                    Thyroid profile   Levels
Primary           Congenital                      T3            ↓
Hypothyroidism    Radiation damage                T4            ↓
                  Surgical removal               TSH            ↑
                  Viral infection
                  Auto-immune
Secondary         Damage to the pituitary         T3            ↓
Hypothyroidism    gland                           T4            ↓
                                                 TSH            ↓
Hyperthyroidism   Graves disease                  T3            ↑
                  Toxic adenoma                   T4            ↑
                  Multi-nodular goitre           TSH            ↓
                  Thyroid hormone
                  overdose
                                                                    13
Tests based on metabolic effects
                       of thyroid gland
Parameter         Measurement &                Clinical Application
                  Normal Levels
Basal Metabolic Benedict Roth apparatus        5 to +20% → Normal
Rate (BMR)      Normal: - 15 to + 20           -10 to + 10% → Euthyroid
                                               < - 20% → Hyperthyroid
                                               + 50% to +75% → Hyperthyroid
Serum total       Zak’s method                 ↑↑↑ levels → hypothyroidism
cholesterol       Cholesterol oxidase method   Normal or lower limit of normal
                  Normal: 150 to 200 mg%       → Hyperthyroidism
Serum creatine    HPLC                         > 1.6 mg% → hyperthyroidism
                  Normal: 0.6 to 1 mg%
Serum uric acid   Uricase method               ↑ levels → myxoedema
                  Normal: 3 to 7 mg%
Serum Creatine Enzymatic                       ↑ levels → hypothyroidism
kinase         Normal: 38 to 300 U/L
                                                                           14
Immunological tests for thyroid functions
 Anti-thyroid antibodies
• anti-TG antibodies → attack thyroglobulin
• anti-thyroperoxidase, or anti-TPO → attack
  thyroperoxidase
• TSH receptor antibodies
 Antithyroid antibodies are present in ‘Hashimoto’s
  disease’
 Antithyroid antibodies are detected in blood by:
  - hemeagglutination
  - RIA
                                                       15
   A 50 year old man who was a chronic alcoholic
    was admitted to the casualty with the complaints
    of severe epigastric pain & vomiting. Symptoms
    started following consumption of a large meal
    after alcohol intake. O/E he had mild fever with
    tenderness in the upper abdominal region.

   What is your probable diagnosis?
   Suggest the biochemical investigations to confirm
    your diagnosis.

                                                    16
Pancreatic Function Tests
 Exocrine functions:
 Secretin test
 Dimethadione test (DMO test)
 Triolein breath test
 Pancreatic insufficiency
 Para amino benzoic acid (PABA) test
 Faecal fat test
 Enzymes: Amylase and lipase
 Endocrine function
 Oral GTT
                                        17
Pancreatic Enzymes
• Amylase
   – only digestive enzyme secreted by the pancreas in
     an active form
   – functions optimally at a pH of 7
   – hydrolyzes starch and glycogen to glucose, maltose,
     maltotriose, and dextrins
   – Reference Range: 50 to 120 U/L
• Lipase
   – function optimally at a pH of 7 to 9
   – emulsify & hydrolyze fat in the presence of bile salts
   – Reference Range: 50 to 175 U/L
Gastric, Pancreatic and
         Thyroid Function Test - Summary
Synthetic peptide used to stimulate gastric    Pentagastrin
secretion
Primary function of thyroid assessment         Radioactive iodine – I131

Decrease in T3, Decrease in T4 & Increase in   Primary hypothyroidism
TSH
Increase in T3, Increase in T4 & Decrease in   Hyperthyroidism
TSH
Anti-thyroid antibodies                        Hashimoto’s thyroiditis
Amylase and lipase levels                      Pancreatitis




                                                                           19
Examination Tips
• Thyroid function test




• Pentagastrin test
• Pancreatic function test




                                20
POST TEST


            21
Thyroid, pancreatic & gastric function test

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Thyroid, pancreatic & gastric function test

  • 1. 1
  • 2.  Case-based large group learning  Total number of slides in presentation: 22  3 case scenarios – each presenter will get 4 min  Last 10 min is for application and summary  Total duration of lecture: 40 to 45 min  Post-test at the end to conclude the chapter: Duration 10 min 2
  • 3.  At the end of the lecture class the learner must be able to:  List the tests done to assess gastric, pancreatic and thyroid function  Categorise the function tests and their importance  Apply them in clinical situations 3
  • 4. Assessment of Gastric functions  Fractional Test Meal (FTM) - requires aspiration of gastric contents - aspiration: ‘Ryle’s tube’  Pentagastrin Stimulation Test - synthetic ‘peptide’ - having biological active sequence of gastrin  Augmented Histamine test - Most potent stimulus of gastric secretion  Serum Gastrin level 4
  • 5. Pentagastrin Stimulation Test  Fasting gastric juice is aspirated by Ryle’s tube → ‘Residual juice’  Gastric juice collected for next one hour is collected → ‘Basal secretion’  Gastric secretion is stimulated by giving ‘pentagastrin’  Dose: 6mg/Kg body weight  Gastric secretion is collected every 15 min for next one hour 5
  • 6. Pentagastrin Stimulation Test  Normal Response by assessment of free and total acidity: Trait Men Women Basal Acid Output 0 to 10 mmol/hr 0 to 5.5 mmol/hr Maximal Acid Output 7 to 45 mmol/hr 5 to 30 mmol/hr Peak Acid Output 12 to 60 mmol/hr 8 to 40 mmol/hr 6
  • 7. Clinical Application – Gastric functions Hyperacidity Hypoacidity Duodenal ulcer Gastritis Gastric cell hyperplasia Gastric carcinoma Carcinoid tumours Partial gastrectomy Zollinger-Ellison syndrome Pernecious anaemia Multiple Endocrine Neoplasia – Type 1 Chronic iron deficiency anaemia Basophilic leukemia 7
  • 8. Classification – Thyroid Function Test  Based on Thyroid Function & Clinical Utility Group I Primary function of Radio-iodine uptake thyroid T3 – suppression test TSH – stimulation test TRH stimulation test Group II Measurement of blood Total T3 and T4 levels levels of thyroid Free T3 and Free T4 levels hormones Circulating TSH level Plasma tyrosine level Group III Metabolic effects of Basal Metabolic Rate Thyroid hormones Serum cholesterol level Serum creatine level Serum uric acid level Serum creatine kinase level Group IV Immunological tests for Agar gel diffusion test auto-immune disorders Complement fixation test 8
  • 9. Tests based on primary function of thyroid  Radioactive ‘Uptake’ studies  I131 → ‘tracer’ used for thyroid studies  Normal: 20 to 40%  TSH – stimulation test  Basal levels of thyroid hormones is measured  3 injections of TSH each of 5 USP units is given 8 hourly  Failure to produce thyroid hormones → Primary hypothyroidism  Stimulation of gland by production of thyroid hormones → secondary hypothyroidism 9
  • 10. A 50 year school teacher came with the complaints of coarse speech, dry skin, puffy face, non-pitting pedal edema, easy fatigability and constipation. Personal history suggested she had noticed gaining weight despite decreased appetite over the past few months. O/E patient had a palpable swelling in front of the neck with brittle nails.  What is your probable diagnosis?  Suggest the biochemical investigations to confirm your diagnosis. 10
  • 11. Measurement of blood levels of thyroid hormones Hormone Method Reference Range Total T4 ELISA 5 to 12 µg/dl Total T3 Chemiluminescence 120 to 190 ng/dl Radioimmunoassay TSH 0.5 to 4.5 mIU/ml Free T3 Chemiluminescence 0.2 to 0.5 ng/dl Free T4 0.7 to 1.8 ng/dl Plasma Tyrosine 60 to 70 µ Mol/L 11
  • 12. A 49 year old female came to the medical OPD with complaints of intolerance to heat, loss of weight in spite of good appetite and excessive sweating. She also complained of excessive hair loss. O/E patient has protruding eyes and tremors of hands.  What is your probable diagnosis?  Suggest the biochemical investigations to confirm your diagnosis. 12
  • 13. Clinical Application of Thyroid Hormone Measurement Disorder Causes Thyroid profile Levels Primary Congenital T3 ↓ Hypothyroidism Radiation damage T4 ↓ Surgical removal TSH ↑ Viral infection Auto-immune Secondary Damage to the pituitary T3 ↓ Hypothyroidism gland T4 ↓ TSH ↓ Hyperthyroidism Graves disease T3 ↑ Toxic adenoma T4 ↑ Multi-nodular goitre TSH ↓ Thyroid hormone overdose 13
  • 14. Tests based on metabolic effects of thyroid gland Parameter Measurement & Clinical Application Normal Levels Basal Metabolic Benedict Roth apparatus 5 to +20% → Normal Rate (BMR) Normal: - 15 to + 20 -10 to + 10% → Euthyroid < - 20% → Hyperthyroid + 50% to +75% → Hyperthyroid Serum total Zak’s method ↑↑↑ levels → hypothyroidism cholesterol Cholesterol oxidase method Normal or lower limit of normal Normal: 150 to 200 mg% → Hyperthyroidism Serum creatine HPLC > 1.6 mg% → hyperthyroidism Normal: 0.6 to 1 mg% Serum uric acid Uricase method ↑ levels → myxoedema Normal: 3 to 7 mg% Serum Creatine Enzymatic ↑ levels → hypothyroidism kinase Normal: 38 to 300 U/L 14
  • 15. Immunological tests for thyroid functions  Anti-thyroid antibodies • anti-TG antibodies → attack thyroglobulin • anti-thyroperoxidase, or anti-TPO → attack thyroperoxidase • TSH receptor antibodies  Antithyroid antibodies are present in ‘Hashimoto’s disease’  Antithyroid antibodies are detected in blood by: - hemeagglutination - RIA 15
  • 16. A 50 year old man who was a chronic alcoholic was admitted to the casualty with the complaints of severe epigastric pain & vomiting. Symptoms started following consumption of a large meal after alcohol intake. O/E he had mild fever with tenderness in the upper abdominal region.  What is your probable diagnosis?  Suggest the biochemical investigations to confirm your diagnosis. 16
  • 17. Pancreatic Function Tests  Exocrine functions:  Secretin test  Dimethadione test (DMO test)  Triolein breath test  Pancreatic insufficiency  Para amino benzoic acid (PABA) test  Faecal fat test  Enzymes: Amylase and lipase  Endocrine function  Oral GTT 17
  • 18. Pancreatic Enzymes • Amylase – only digestive enzyme secreted by the pancreas in an active form – functions optimally at a pH of 7 – hydrolyzes starch and glycogen to glucose, maltose, maltotriose, and dextrins – Reference Range: 50 to 120 U/L • Lipase – function optimally at a pH of 7 to 9 – emulsify & hydrolyze fat in the presence of bile salts – Reference Range: 50 to 175 U/L
  • 19. Gastric, Pancreatic and Thyroid Function Test - Summary Synthetic peptide used to stimulate gastric Pentagastrin secretion Primary function of thyroid assessment Radioactive iodine – I131 Decrease in T3, Decrease in T4 & Increase in Primary hypothyroidism TSH Increase in T3, Increase in T4 & Decrease in Hyperthyroidism TSH Anti-thyroid antibodies Hashimoto’s thyroiditis Amylase and lipase levels Pancreatitis 19
  • 20. Examination Tips • Thyroid function test • Pentagastrin test • Pancreatic function test 20
  • 21. POST TEST 21