LIVER FUNCTION TESTS

Tests that are of very much useful to diagnose and monitor the liver diseases are called as liver function tests.

Functions of liver
Excretion of bile pigments, bile salts, BSP(Bromsulphthalein ) and ICG(indocyanin green) Metabolism of carbohydrates, amino acids and lipids. Synthesis of serum proteins albumin and prothrombin. Detoxification of ammonia and hippuric acid. Serum enzymes.

Classifiation
Tests based on Excretory function Tests based on synthetic function. Tests based on metabolic capacity of liver Tests based on serum enzymes.

Tests based on Excretory function

BILIRUBIN It is the excretory product formed due to catabolism of heme. It is conjugated by the liver to form bilirubin diglucuronide and excreted through bile. Normal levels varies from 0.2-0.8mg/dl Unconjugated bilirubin- 0.2 0.6mg/dl Conjugated bilirubin- 0-0.2mg/dl

Estimation of bilirubin in serum

By Van den bergh reaction. Diazotised sulfanilic acid + bilirubin Azobilirubin ( The red-violet compound) Conjugated bilirubin Direct positive Unconjugated bilirubin Indirect positive Both - biphasic

Urinary findings in jaundice

Type of jaundice Prehepatic Hepato cellular Post hepatic Bile pigment Nil ++ +++ Bile salt Nil + ++ Uro bilinogen ++ Normal or decreased Nil or decreased

Tests in urine
Bile pigments Fouchets test. Bile salts Hays test

Urobilinogen Ehrlichs test.

Jaundice
Jaundice is increased levels of Ser Bil > 1.0 mg%. Latent jaundice - >1mg%, <2mg% Types of Jaundice : 1.Pre hepatic From hemolysis of RBC (Hemolytic) 2.Hepatic - Hepatocellular dysfunction in handling bilirubin - Uptake, Metabolism and Excretion of bilirubin 3.Post hepatic - Obstruction to bile flow (Obstructive)
Intrahepatic cholestasis Extrahepatic Obstruction (Surgical Jaundice

Table of diagnostic tests Function test Total bilirubin Conjugated bilirubin Unconjugated bilirubin Urobilinogen Urine Color Stool Color Alkaline phosphatase levels ALT and AST levels Conjugated Bilirubin in Urine Increased Present Increased Pre-hepatic Jaundice Normal / Increased Hepatic Jaundice Increased Normal Normal / Increased Normal / Increased Dark Pale Increased Increased Normal Decreased / Negative Post-hepatic Jaundice

BSP(Bromsulphthalein RETENTION TEST)

The ability of the liver to excrete certain dyes is utilized in this test. PROCEDURE A single bolus dose of BSP 50g/L, is given & the serum concentration is measured at 45mins & at 2hrs. Normal response the retention at 45mins is <5%. Liver disorders impairment of liver cell function will cause an increase in BSP retention.

Note : contraindicated in obstructive jaundice.

Tests based on metabolic capacity of liver

Galactose tolerance test Galactose is almost exclusively metabolised by liver. The rate of utilisation of galactose is proportional to the functional liver mass. Procedure - 350mg galactose/kg body weight is given intravenously within 3mins. Then blood is collected at 10mins interval for 1hour. The half life of galactose in blood is about 1015mins in normal people. The half life is increased in cirrhosis and infective hepatitis patients.
C14 labelled galactose given CO2 eliminated may be assessed.

Plasma amino acids

The amino acid profile is abnormal in hepatic coma. The level of aromatic amino acids is increased.

Tests based on abnormalities of lipids Total cholesterol 150-250mg%, & 60 -70% of this is esterified. Obstructive jaundice increase in TC A/c Hepatic necrosis TC is usually low and may fall below 100mg%, and also marked decrease in % of esters.

Tests based on synthetic function Blood albumin level 1.all serum proteins are synthesised by the liver
except immunoglobulins. 2.Serum albumin is quantitatively the most important protein synthesised by the liver and reflects the functioning of liver cell mass. 3.it is not a good indicator of acute liver diseases as its half life is long. In chronic diseases its level is decreased. 4.normal level Albumin 3.5 5g/dl. Globulin 2.5 3.5g/dl Reversal cirrhosis

Prothrombin time Prothrombin is synthesised by the liver. Vit K deficiency as the cause for prolonged PT may be ruled out by estimating the PT before and after parenteral administration of Vit K. In case of liver disease the PT remains prolonged even after administration of vit K. Prolonged PT poor prognosis.

Tests based on detoxification function of liver

HIPPURIC ACID TEST Liver removes benzoic acid by combining with amino acid glycine forming hippuric acid. Test depends on 2 factors

1. ability of the liver to produce and provide sufficient glycine

2. the capacity of liver cells to conjugate with benzoic acid

 Procedure Dissolve 6 gms of sodium benzoate in

200 ml of water . The patient is asked to drink this solution and time is noted . (bladder should be emptied before consuming the solution). The bladder is again emptied 4 hours later. The amount of hippuric acid excreated in this 4 hours is estimated.

Interpretation normally 3 gm of hippuric acid

should be excreted.

In liver disorders - either acute or chronic small amounts are excreted.

Tests based on serum enzymes.

SGOT (AST) - <45U/L

SGPT (ALT) - <50U/L

Both enzymes are found in most tissues, but relative amounts vary. - heart muscles are richer in SGOT, liver contains more of SGPT. The level of aminotransferaces in serum are elevated in all liver diseases, with SGPT higher than SGOT. Highest levels seen in viral & toxic hepatitis. Degree of elevation is directly proportional to hepatocellular necrosis. Their determination is of extreme use in assessing the severity and prognosis of parenchymal liver diseases especially A/c infectious hepatitis and

Marker enzymes for obstructive liver disease ALP - 12-115U GGT- 10 30U/L 5nucleotidase - 2-10U/L Leucine amino peptidase. ALP ALP is an ecto enzyme that is localised in cell membranes & is associated with transport mechanisms in liver, kidney & intestinal mucosa. Very high levels cholestasis or hepatic ca. The bile duct obstruction induces the synthesis by the biliary tract epithelial cells. Parenchymal liver diseases mild elevation

GGT : It transfers gamma glutamyl residues. Moderate elevations seen in infective hepatitis and prostrate cancer, MI, panreatic disease, renal failure, COPD. Highly elevated in alcoholism, obstructive jaundice and neoplasms of the liver. GGT elevation parallels that of ALP & is very sensitive to biliary tract disease.

5'Nucleotidase

It is a marker enzyme for plasma membranes ans is seen as an ectoenzyme. It is moderately increased in hepatits and highly elevated in biliary obstruction. It parallels the levels of ALP.

Leucine amino peptidase Elevated levels noticed in hepatobiliary disease, obstructive jaundice and pregnancy.