LIVER FUNCTION

Liver

two-cell thick internal organ

Hepatocytes- liver cells
sinusoids- capillary spaces between hepatic plates
Kupffer cells- macrophage present in liver

Because the sinusoids are filled with blood, each hepatocyte has a direct contact with the
blood.
Blood is delivered to the liver via the two blood vessels:

Hepatic portal vein- drains substances (enterohepatic circulation)

Hepatic artery- drains from general circulation

Liver Microstructure
Liver lobules- functional units of the liver
Components:
1. Central vein- drains blood from the sinusoids to the hepatic vein that eventually
goes out of the liver carrying it to the general circulation
2. Branches of the hepatic portal vein and the hepatic artery- deliver blood into
the sinusoids between hepatic plates
3. Sinusoids- spaces between hepatic plates
4. Hepatic plates- lined with one to two layers of hepatocytes
5. Bile canaliculi- spaces within hepatic plates
6. Bile ducts- carry bile and drain it into the hepatic ducts bringing it to the gallbladder
and eventually to the duodenum of the SI
There is no mixing of the bile and the blood under normal circumstances. Why?

The arterial blood from the hepatic artery and the venous blood from the hepatic portal
vein mix in the sinusoids and are drained by the central vein. All central veins coverage
into the hepatic vein.
The bile produced by the liver hepatocytes is delivered to the bile duct via the bile
canaliculi.

Liver Functions

The carbohydrate metabolic function may be assessed by measuring RBS.

The synthetic function may be monitored by measuring levels of albumin and
coagulation factors.
To assess integrity of liver cells, liver enzymes can be measured.

Bile Components:

bile acids
lecithin
cholesterol
bilirubin
urobilinogen
electrolytes (Na, K, Cl, HCO3-)
The function of bile is to help in lipid digestion in small intestine. The ability of bile acids, the
major component of bile, is to form micelles is responsible for this biologic function.
Most common bile acids are: cholic acid and chenodeoxycholic acid.

Classification of Liver Function Tests

Bilirubin

bile pigment that results from the catabolism of the heme moiety of the hemoglobin
molecule due to old age or trauma.
degradation of bilirubin occurs in spleen, BM and liver
Normal concn of bilirubin in blood (mostly free type): 0.5-1.0mg/dL

How bilirubin is formed?

1. Hemoglobin molecule is broken down into heme and globin.
2. The globin is catabolized to release its amino acids, which then enter the amino acid
pool. The iron component of the heme portion is brought to the iron stores
(ferritin of the body).
3. The rest of the fragments is catabolized first into biliverdin by the enzyme heme
oxygenase.
4. The biliverdin produced is then reduced into free bilirubin (aka B1) by biliverdin
reductase.
5. Since free bilirubin is not soluble in water, therefore it must be carried in the blood
attached to albumin. One mole of albumin binds with two moles of bilirubin. This
type of bilirubin cannot be filtered by kidney nor directly excreted by the liver into the
bile.
6. The liver will take some free bilirubin out of the blood and conjugate it with
glucoronic acid to form the conjugated bilirubin. This is through by uptake of free
bilirubin by the hepatocytes.
Once in the cytoplasm of the liver cells, the free bilirubin binds with ligandin
and Z protein, and is conjugated with two molecules of glucoronic acid (a
derivative of glucose catalyzed by UDP-glucoronyl transferase. The
conjugated bilirubin or bilirubin diglucoronide (aka B2) is thus rendered
water soluble and can now be secreted into the bile.
7. Once the conjugated bilirubin is in the SI, it is converted by the bacteria into pigment
called urobilinogen. This pigment may then be converted into stercobilin, which is
partly responsible for the color of the feces.

8. 30-50% of the urobilinogen is absorbed by the intestine and enters the hepatic portal
vein.
9. From the liver, urobilinogen, which is not bound to any protein, gets into the kidney
where it is filtered and excreted in the urine as urobilin, which gives urine its
characteristic color.
Delta () bilirubin

happens when a small fraction of bilirubin forms a covalent bond with protein
usually seen in patients with long-standing conjugated bilirubinuria (presence of B 2 in the
urine)

Difference between free and conjugated bilirubin

Hyperbilirubinuria

increased bilirubin levels in blood

two types: Conjugated Hyperbilirubinuria and Unconjugated Hyperbilirubinuria

Jaundice

yellowish pigmentation of skin, mucus membrane and sclera of the eyes (bilirubin has
high affinity with the elastin of the sclera)
due to the accumulation of abnormal amounts of either free or conjugated bilirubin or
both
Bilirubin levels in blood with jaundice: 2mg/dL

Erythroblastosis fetalis- jaundice in newborn babies caused by a high rate of red cell
destruction, therefore there is high levels of free bilirubin in the blood
Physiological jaundice of the newborn- type of jaundice in newborns caused by rapid
fall in blood Hb concns that normally occurs at birth, or in premature infants it may be
caused by inadequate amounts of hepatic enzymes that are needed to conjugate and thus
excrete it in the bile
Newborn infants with jaundice are treated with phototherapy (babies are placed under blue
light in the 400-500m, wavelength range). The light is absorbed by bilirubin and results in

the conversion of bilirubin to a more polar isomer, which is soluble in plasma without having
to be conjugated with glucuronic acid. Then it can be excreted in bile or urine.

Classes of Jaundice
Pre-hepatic jaundice

aka hemolytic or retention jaundice

due to excessive destruction of RBC
Only the free bilirubin fraction is elevated
elevation could be overproduction of bilirubin like in HDN and malaria;
or hepatic uptake of bilirubin may be decreased in prolonged fasting and intake of drus;
or bilirubin conjugation is decreased like in Gilberts, Crigler-Najjar I and II, physiologic
neonatal jaundice

Hepatic jaundice

aka hepatocellular or infectious jaundice

occurs when there is a severe damage to the hepatocytes, possibly due to
microorganisms or alcohol
both free and conjugated bilirubin may be elevated

Post-hepatic jaundice
aka regurgitative, obstructive, or cholestatic jaundice
due to obstruction in biliary flow
elevation of B2
could be a consequence of impairment of hepatic excretion as in familial disorders
(Dubin-Johnson syndrome, Rotor Syndrome, intra-hepatic cholestasis) or acquired
disorders (drug-induced cholestasis)
or obstruction of the extra-hepatic biliary tree as in gallstones (cholelithiasis), strictures,
spasms, atresia, parasites or bacteria, or pancreatic cancer
Characteristics of Cholestasis
1.
2.
3.
4.

hyperbilirubinemia with bilurubinuria

elevations of ALP, yGT, 5N and LAP
hypercholesterolemia (as high as 1000mg/dL) where xanthomas appear
high serum bile salts (cholate and chenodeoxycholate)

Patients with cholestasis manifests: dark urine, intense itching over the skin, pale and fatty
stools, and jaundice, increased bilirubin which may persist even cholestasis is relieved

Difference between Pre and Post Hepatic Jaundice

Inherited Disorders of Bilirubin Metabolism

Gilberts Disease- characterized by decreased conjugation and decreased uptake of
bilirubin. It is a pre-conjugation failure; there is increased B 1
Criggler- Najjar Syndrome- two types:
Type 1- autosomal recessive; absence of enzyme UDPGT; increased B 1 (severe)
Type 2- autosomal dominant; there is only partial defect of conjugating enzyme; increased
B1 but patient may survive up to childhood
Dubin-Johnson Syndrome- characterized by a decreased hepatic secretion of bilirubin;
there is increased B2 with hepatic pigmentations
Rotor Syndrome- unknown cause; similar to Dubin-Johnson but no hepatic pigmentation; is
increased B2

Bilirubin Determination
Van den Bergh Reaction
aka diazotization reaction
Bilirubin + Erlichs diazo reagent pink to purple azobilirubin
Erlichs diazo reagent is composed of diazotized sulfanilic acid which is formed by reacting
sulfanilic acid with sodium nitrite and hydrochloric acid
in the process, one molecule of bilirubin splits to two molecules of azobilirubin

Two Methods of Bilirubin Determination using Diazotization Reaction:

Evelyn-Malloy Method

diazo product has a red to reddish purple color in acid pH

product has absorption maximum at 560nm
dissociating agent: methanol
modifications: microbilirubin determination, Amino-Ducci-Watson Method, StonerWiseberg Method

Jendrassik-Grof Assay

color shifts to blue in alkaline pH

maximum absorption is 600nm
dissociating agent: mixture of caffeine and sodium benzoate
dissociating agent is better than methanol because methanol shows turbidity due to
precipitation of protein in the sample

modifications: Michaelson, Thamhauser-Anderson, Alkaline methanolysis, direct reading

bilirubinometer

Reminders on Bilirubin Assay:

Dont use hemolysed samples because there is release of Hb in serum which could be an
interference due to its absorption close to 560nm
Dont exposed the samples to light since bilirubin is light sensitive
If hemolysed samples will be used, use ample blanks to correct this interference