1. A 65-year-old male presented with fever, abdominal pain, distension, and jaundice for 4 weeks. Imaging showed a diffuse process in the liver. Liver biopsy revealed adenocarcinoma infiltration of the liver.
2. A 58-year-old female with diabetes and elevated liver enzymes was evaluated. She had a history of elevated enzymes attributed to lipid medication years ago. Current labs showed elevated AST and ALT with normal ALP and GGT. She had weight gain and abnormal lipid profile.
3. The first case describes a patient with diffuse liver lesions found to be metastatic adenocarcinoma on biopsy. The second case involves a patient with metabolic risk factors and elevated amin
3. Anatomy LiverAnatomy Liver
The liver is the largest
organ in the body
It is located below the
diaphragm and extended
approximately from the
right 5th rib to the lower
border of the rib cage.
7. Exogenous Endogenous
Bile and Urine
1.Carbohydrate metabolism
2.Harmone metabolism
3.Lipid metabolism
4.Protein and drug
8. LFTs are classified asLFTs are classified as::
Excretory function tests: Bile pigments, salts,
acids, bilirubin
Metabolic functions tests : Carbohydrates,
Protiens, Fats
Synthetic capabilities : Protiens(albumin),
coagulation factors
Detoxification : Ammonia, drugs
Tests of liver injury : Enzyme assays, autoimmune
markers, markers of hepatitis virus infections
9. Uses of LFTsUses of LFTs
Diagnosis of type of jaundice- etiology
Assess severity & follow trend of liver disease
Detect latent liver disease
Screening of infective hepatitis
Screen drug hepatotoxicity
10. Indication and limitation of LFTIndication and limitation of LFT
Indication-
◦ Screen for liver diseases
◦ Identifying the nature of liver
diseases( hepatocellular, cholestatic, or
infiltrative.)
◦ Assess severity and prognosis of liver disease
◦ Follow up the course of liver disease.
Limitations –
◦ Do not necessarily assess liver function.
◦ Lack sensitivity
◦ Lack specificity
11. Tests included under LFTTests included under LFT
1. Total Bilirubin
2. Conjugated Bilirubin
3. Total protien
4. Albumin
5. Coagulation factors.
12. EnzymesEnzymes
Introduction
1. Enzymes are biological catalysts that speed up the
rate of the biochemical reaction.
2. Most enzymes are three dimensional globular
proteins (tertiary and quaternary structure).
3. The molecule for which enzyme catalyzes reaction is
called Substrate.
14. How do enzyme work??How do enzyme work??
By lock and key mechanism.
Converts the complex structures into simple structures
15. Concentration & ActivityConcentration & Activity
Depends on rate of synthesis and degradation
Control occurs at transcriptional and translation
levels
Do not effect the value of equilibrium – constant
between reactants and products.
The 3 dimensional shape of the active site is a vital
determinant in recognition and specificity of
process.
16. Enzyme classificationEnzyme classification
Class type Reaction catalyzed
Oxidoreductases Oxidation–reduction reactions
Transferases Transfer of functional groups
Hydrolases Hydrolysis reactions
Lyases Group elimination to form double
bonds
Isomerases Isomerizations
Ligases Bond formation coupled with
ATP hydrolysis
17. Factors affecting plasma activityFactors affecting plasma activity
1. Increased release
Necrosis of cell
Increased permeability of the membrane
Increased synthesis
Increase in tissue source of enzyme in
malignancy.
2. Impaired deposition
Increased levels in obstructive jaundice
Increased levels in renal failure.
24. Aspartate transaminaseAspartate transaminase
Biochemistry & Physiology
1. Normal range – 5- 40 IU/Lt.
2. Half life – 17hrs.
3. Its 7000 times more than the plasma
4. Catalyzes the reversible transfer of aspartate
group
Alpha ketoglutarate Glutamate +
Oxaloacetate
AST
26. 2 forms of AST are known-
1. Cytosolic
2. Mitochondrial (mAST) – it is synthesized in
precursor form (pre-mAST)
converted to mature mAST
•mAST/total AST ratio – marker of chronic alcohol
consumption
27. Alanine transaminaseAlanine transaminase
Biochemistry & Physiology
1. Normal range – 5- 40 IU/Lt.
2. Half life – 47hrs.
3. Its 3000 times more than the plasma
4. Catalyzes the reversible transfer of Alanine group
Alpha ketoglutarate Glutamate +
Pyruvate
ALT
29. Diagnostic significance ofDiagnostic significance of
TransaminasesTransaminases
Levels of >1000 IU/L occurs in –
Acute viral hepatitis
Toxin and drug induced hepatitis
Ischaemic liver injury
In most acute hepatocellular disorders ALT is
higher or equal to AST
30. ALT is usually normal in alcoholic liver disease ;
can be sometimes low due to an alcohol
induce deficiency of pyridoxal phosphate
AST/ALT <1 is seen in Non Alcoholic Staeto
Hepatitis and viral hepatitis
31. Determination of these enzymes are helpful in
distinguishing hepatocellular from cholestatic
jaundice
Increase in AST and ALT is much more ( >500
IU/L)in hepatocellular jaundice than in cholestatic
jaundice (>200 IU/L)
Persistence of elevated ALT and AST beyond 6
months in a case of hepatitis indicates
development of chronic hepatitis
32. AST/ALT RATIOAST/ALT RATIO
Normal AST/ALT ratio is 0.8.
A ratio > 2 is seen in
1. Alcoholic hepatitis
2. Hepatitis with cirrhosis
3. Non alcoholic steatohepatitis
4. Liver metastasis.
5. Myocardial infarction
6. Erythromycin treatment
33. Continu…Continu…
A low ratio (ALT is higher) is seen in
1. Acute hepatocellular injury
2. Toxic exposure
3. Extrahepatic obstruction (cholestasis)
34. Assay for AST & ALTAssay for AST & ALT
Vit B6 important requirement for AST and ALT assays
Normal serum levels upto 40 IU/dl for both
↑ Aspartate in reaction glutamate→ α ketoglutararte
Glutamate
dehydrogenase
NAD NADH(Colour indicator)
Oxaloacetate malate
malate
dehydrogenase
NAD NADH(Colour indicator)
Measured
spectrophotometrically
37. Mild Chronic Elevation inMild Chronic Elevation in
Serum AminotransferasesSerum Aminotransferases
Step one
◦ Medications and supplements
◦ Alcohol use
◦ Viral hepatitis B and C
◦ Hemochromatosis
◦ Fatty liver (hepatic steatosis and
steatohepatitis )
40. Mild Chronic Elevation inMild Chronic Elevation in
Serum AminotransferaseSerum Aminotransferasess
Step four
◦ A liver biopsy is often considered in patients
in whom all of the above testing has been
unyielding.
◦ However, in some settings, the best course
may be observation.
42. 3 enzyme activities are important –
1.Alkaline phosphatase (ALP)
2. 5’nucleotidase (5’NT)
3. Gamma glutamyl transferase (GGT)
43.
44. Alkaline phosphatesAlkaline phosphates
• Biochemistry and Physiology
1. Type of hydrolase
2. Plasma ALP forms are coded by single gene on
chromosome 1- producing tissue nonspecific
enzymes.
3. Two other genes on chromosome 2 – Code for
placental & intestinal origin of ALP.
45. 4. Bound to cell membranes.
5. Facilitate the movement of substances across cell
membrane.
By cleavage of pyrophosphate
6. Released by ingestion of Fatty foods.
7. The half life of isoenzymes of ALP
• Intestine – 1 minute
• Bine – 1 day
• Liver – 3 days
• Placenta – 7days.
46. Reference range and preanalyticalReference range and preanalytical
variationvariation
Normal - 39-117 IU /Lt
Peak in Teens
Increases in postmenopausal women – Bone
isoenzymes
Increase in ALP seen in
1. High body mass index
2. Antiepileptic agents
3. Smoking
47. Continu….Continu….
Decrease in ALP is seen in
1. Oral contraceptives
2. Fibric acid derivatives.
3. Blood transfusion
4. Cardiopulmonary bypass
48. • Increases in > 10 times of nomal
1. Obstruction of biliary tract – by stones in ducts.
2. Space occupying lesions
3. Ascending cholangitis
49. Assay of ALPAssay of ALP
• By using p- nitrophenyl phosphate as a substrate
in alkaline pH
Inorganic phosphate + highly colored para –
nitrophenoxide anion.
Measured by spectrophotometer at 340nm.
Hydrolysis
50.
51. Gamma glutamyl transferaceGamma glutamyl transferace
• Regulates the transport of aminoacids across the
membrane.
Glutathion
GGT
Free amino acid
• Clinically used to differentiate the increased level
of ALP in biliary tract disease from bone
disease.
• Half life – 10days.
52. • Serum GGT is increased in = >10times of the
normal
1. Alcoholism
2. Chronic Cholestasis
3. Malignant infiltration of the liver
4. Drugs - acetaminophen and phenytoin and
carbamazepine ( 5 times the normal)
• GGT and 5’NT is especially used to assess the
nature of ALP
53. Assay of GGTAssay of GGT
• Most assays for GGT utilize the substrate -γ
glutamyl–p-nitroanilide.
• In the reaction catalyzed by GGT
• p-nitroaniline is liberated
chromogenic
measured by spectrophotometer
54. 5’Nucleotidase5’Nucleotidase
• Biochemistry and physiology
1. Is a phosphoric monoester hydrolase.
2. Aslo called 5’ Ribonucleotide phosphohydrolase
3. 5’ Ribonucleotide + H2O = Ribonucleoside + PO4
4. It’s a cytoplasmic membrane bound phosphatase.
56. Reference range and preanalyticalReference range and preanalytical
variationvariation
5 -NT is normally present at low activities in′
children, rises in adolescence and plateaus until
age 40
Increase in 5’ NT - 2nd
and 3rd
trimester of
pregnancy.
Increase in Antiepileptic drug intake.
57. • Assay of 5’ Nucleotidase
1. By measurement of nucleoside released by action
of 5’NT is required.
• Causes of abnormal result
1. Acute hepatitis
2. Ovarian carcinoma
3. Rheumatoid arthritis
58. Lactate dehydrogenaseLactate dehydrogenase
• Biochemistry and physiology
1. Is a Oxidoreductase enzyme
2. Acts on CH-OH group of donors with NAD+ as
acceptor.
Lactate + NAD+ Pyruvate +NADH+ H+
3. Major isoenzyme – 4 tetramers
H(lactate)
M (pyruvate)
62. Case 1Case 1
65 yr old male with history of fever and altered
bowel habits , abdominal pain and distention pof
abdomen sincev 4 weeks.
tender hepatomegaly
Ascitis , Icterus - +
Bilirubin – 11 Albumin – low
ALT - 30 Cultures - negative
AST - 84 Antibiotics – No help
ALP - 820 PT - High
GGT – 468
63. USG - Possible diffuse process
Repeat CT – no focal lesions.
Became coagulopathic and tachycardiac.
DIAGNOSIS ??
64. Liver biopsy - Multiple lesions seen –
Adenocarcinoma.
Liver infiltration by carcinoma.
65.
66.
67.
68. Case 2Case 2
58-year-old with type 2 diabetes was sent for
evaluation to the hepatology clinic with persistent
elevation of liver enzymes and complaints of
fatigue, dull right upper quadrant abdominal pain,
nausea and mild leg swelling for the past 3–4
months.
From routine laboratory data 3–4 years ago the
patient was found to have mildly elevated liver
enzymes, which was attributed to a lipid-lowering
agent (niacin), which was stopped at that time.
she has not been on lipid-lowering medication
since then
69. . Laboratory work was not repeated until recently,
when she was found again to have elevated
aminotransferase levels.
Past history – uneventful except for the 6kg
wieght gain .
CBC –normal
Albumin - 3.2 g/dL
AST - 67 U/L
ALT - 89 U/L
ALP -166 U/L
GGT - 70 U/L
70. Total cholesterol - 212 mg/dL
LDL cholesterol - 144 mg/dL
Triglycerides - 316 mg/dL
USG abdomen – hepatomegaly
Liver biopsy - significant fatty change (60%) .Portal
areas showed mild chronic lymphocytic infiltration
without interface changes. Hepatic lobules showed
significant hepatocyte degeneration (balloon
degeneration and Mallory hyaline) and moderate
inflammatory infiltrate consisting of lymphocytes
and neutrophils.