Bile canaliculi - are small spaces between

LIVER FUNCTION the hepatocytes that form intrahepatic

Characteristics of Liver ducts joins to form the left and right
 Upper right quadrant of the hepatic ducts where excretory products
abdominal cavity beneath the of the cell can
diaphragm and extend approximately drain.
at from the right 5th to the lower - The left and right hepatic ducts merge to
border of the rib cage.  Largest form common hepatic duct.
internal organ (1500 grams)  - Common hepatic duct will merge to
Biochemical role in SYNTHESIS, cystic hepatic duct of the gallbladder to
METABOLISM, DIGESTION and form the common bile duct.
DETOXIFICATION
- Combined digestive secretions are then
Gross Anatomy expelled in the tuberin.
 Consist of 2 lobes divided by falciform
ligament MICROSCOPIC ANATOMY
 No known difference between the
- Lobules make up the liver
lobes
- 6-sided structure
VASCULAR ORGAN: - Central vein with portal triads at each
Hepatic artery corner
 Supplies O2 rich blood from heart to - Triad contains a hepatic artery, portal
liver vein and bile duct surrounded by
connective tissue
 Provides 25% of blood supply to liver
Portal vein - Function in metabolic & excretory
 Supplies nutrient rich blood from the actions Cell types:
digestive tract
1. Hepatocytes
 Provides 75% of blood to liver
- 70% of volume of liver
VASCULAR SYSTEM: - Regenerative
- Hepatic artery and portal vein will - Perform major functions of
eventually merge into the hepatic liver
sinusoid. From the sinusoid, blood flows 2. Kupffer cells
to the central canal (central vein) of each - Macrophages acting as
lobule. It is through the central canal phagocytes
that blood leaves the liver.
- Approximately 1500 ml of blood passes Biochemical Function of the Liver
through the liver per minute.  Excretion/Secretion
- The liver is drained by collecting systems  Synthesis
of vein that empties into the hepatic
 Detoxification
veins and ultimately into the inferior
vena cava.  Storage
 Immunologic
EXCRETORY SYSTEM (BILIARY SYSTEM):

- Begins at the bile canaliculi

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EXCRETORY AND SECRETORY SYSTEM
 Excretion of bile acids, cholesterol,
bilirubin
 Begins at the bile canaliculi, enters
hepatic duct then to common
hepatic & bile duct
The goal is to eliminate heme waste!!!
1. Hemoglobin is broken down into globin,
iron and heme
2. Heme is converted to Bilirubin and bound
by albumin (B1) then transported to the
liver.
3. In the liver (sinusoids), B1 is released from
albumin and picked up by ligandin
4. Ligandin carries B1 to the smooth ERA for
conjugation forming B2. (conjugated
bilirubin)
5. B2 is secreted from the hepatocyte to the
intestine, which bacteria
metabolized to urobilinogen
6. Urobilinogen is oxidized to Stercobilin
(80%) & recycled through the liver
(20%), filtered in the kidneys
BILE
 Water, electroclytes, phospholipids, bile
salts or acids, bile pigments, cholesterol,
heme waste products, and other
substances from blood
 3L produced/day
 1L excreted/day
 Bilirubin is the principal pigment of bile
Functions of bile:
 Bile acids needed for fat absorption
 Mechanism to remove cholesterol and
waste
Metabolism of Bilirubin
 Around 126 days, RBCs are phagocytized
and hgb is released.
 Hgb broken down into:
 Heme- Converted to bilirubin
 Globin- Broken into amino acids and
recycled
 Iron- Bound by transferrin and returned to
iron stores in the liver or bone marrow
 Bilirubin is bound by albumin and taken to
liver (unconjugated or indirect
bilirubin)
Water insoluble (B1)
Cannot be removed from the body
 Once at the liver, unconjugated bilirubin
flows into sinusoidal tissue and albumin
releases it.
 Ligadin picks up the unconjugated bilirubin
and presents it to glucorinic
acid
 In the liver it comes conjugated with the
help of UDP-glucoronyl trasferase Water
soluble (B2)
Combines with gallbladder secretions and
expelled into intestines
 Intestinal bacterial degrade conjugates
bilirubin to form urobilinogen 80% of
urobilinogen formed is oxidized to
stercobilin and excreted in feces, giving
stool the brown color.
20% of urobilinogen formed
 Absorbed by extrahepatic circulation to
be recycled
through the liver and
reexcreted
 Enters systemic circulation to be filtered by
kidneys and excreted in urine.
Excretion: Bilirubin Bilirubin – main bile
pigment that is formed from the
breakdown of heme in RBCs. The broken
down heme travels to the liver, where it is
secreted into the bile by the liver.
 Normally, a small amount of bilirubin
circulates in the blood.
Serum bilirubin – is considered a true test
of liver function, as it reflects the liver’s
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 ability to take up, process and secrete - NOTE!! Bilirubin in urine may be
bilirubin into the bile. detected even before clinical jaundice is
noted.

Indirect bilirubin (unconjugated bilirubin) BIOLOGICAL COMPOUND SYNTHESIS

(normal value = 0.2 – 0.8 mg/dl)  Carbohydrates
Direct bilirubin (conjugated bilirubin)  Lipids
 Proteins
(normal value ≤ 0.2 mg/dl)
1. Carbohydrate Synthesis
Total bilirubin
Metabolism importance
(normal value = 0.2 – 1.0 mg/dl)
 Uses glucose for its own
cellular energy
 Circulates glucose to
URINE/FECES peripheral tissue
A. Urobilinogen  Stores glucose as glycogen
- Conjugated bilirubin is excreted via bile Major player in maintaining stable
salts to intestine. Bacteria in the glucose concentration due to
intestine break down bilirubin to glycogenesis, glycogenolysis and
urobilinogen for excretion in the feces gluconeogenesis.
(normal value of fecal urobilinogen = 40
– 280 mg/day) 2. Lipid synthesis
- Normally, there are mere traces of - Liver gathers free fatty acids from diet
urobilinogen in the urine. Average is and breaks them down to Acetyl-CoA to
0.64 mg, maximum normal 4mg/24 hrs. form triglycerides, phospholipids or
B. Urobilin cholesterol
Urobilin – final product of oxidation of - Converts insoluble lipids to soluble
urobilinogen by oxygen in air. The forms
amount change with the amount of
- 70% of cholesterol produced by the liver
urobilinogen excretion.

Bilirubin in urine: 3. Protein Synthesis

- Bilirubin is not normally present in urine  Almost all proteins are made in the liver
and feces since bacteria in intestine  Exceptions are immunoglobulins and hgb
reduce it to urobilinogen. The kidneys do
not filter unconjugated bilirubin because
DETOXIFICATION
of its avid binding to albumin.
- Conjugated bilirubin can pass through  Liver serves as a gatekeeper between the
glomerular filter. circulation and absorbed substances First
- Bilirubin is found in the urine in pass: every substance absorbed in
obstructive jaundice due to various GI tract passes through liver
causes and in cholestasis.

. 3
  Detoxification includes drugs Classification of Jaundice
and poisons, and metabolic products like - Cause: too much bilirubin presented
ammonia, alcohol and bilirubin 3 to liver
mechanisms: - Result:
 Increase in
 Binds material rerversibly to inactivate unconjugated bilirubin
 Chemically modify compound  Total bilirubin: Increased or
for excretion normal
 Drug metabolizer for detox of drugs and  Increase in serum iron
poisons
Examples: acute/chronic hemolytic anemias
STORAGE
2. Hepatic
 Glycogen - Intrinsic liver disease or
 Vitamins defect - Caused by:
 Iron  Disorders of bilirubin conjugation
 Blood  Disorders of bilirubin transport
 Hepatocellular injury or
IMMUNOLOGIC
destruction
 Phagocytosis of bacteria  Cirrhosis
 IgA secretion  Tumors
 Infection
Alterations in Liver Function
 Toxins
1. Jaundice/Icterus  Intrahepatic
 Yellow discoloration of the skin, eyes obstructions
and mucous membrane
INHERITED HYPERBILIRUBINEMIAS
 Due to the presene of bilirubin

 Prehepatic
 Hepatic
 Posthepatic

1. Prehepatic
- Abnormality is outside the liver
- Liver function is normal
 Onset seen at bilirubin levels > 3.0  Gilbert Syndrome
mg/dl - Reduction in the activity
 Kernicterus UDPglucoronyl transferase
- Yellow staining of the meninges of  Crigler-Najjar syndrome
the brain due to bilirubin - Defective UDP-glucoronyl transferase
- Found in newborns  Dublin-Johnson disease
- Causes brain damage - Post-conjugation failure

. 4
 Class of Type of Causes
Jaundice Bilirubin
raised
Pre-hepatic or Unconjugated Abnormal red cells;
hemolytic antibodies; drugs
ACQUIRED HYPERBILIRUBINEMIAS
and toxins;
thalassemia;
Hemoglobinopathies
Hepatic or Unconjugated Viral hepatitis, toxic
hepatocellular and hepatitis,
conjugated intrahepatic
cholestasis, Gilbert’s
Crigler-Naajjar
syndrome
Post-hepatic Conjugated Extrahepatic
cholestasis;
 Neonatal jaundice
gallstones; tumors of
- Deficiency of glucoronyl
the bile duct,
transferase
carcinoma of
- Causes an increase in unconjugated pancreas
bilirubin
OTHER LIVER DYSFUNCTIONS:
- Leads to kernicterus
- Treat by exposure to UV light or • Reye’s Syndrome
exchange transfusion • Cirrhosis
• Drug & Alcohol Disorders
3. Posthepatic • Hepatitis
• Abnormality is outside the liver
• Liver function is normal
• Biliary obstruction due to
gallstones, tumors, edema
• Stool turns clay-colored due to lack of bile  Reye Syndrome
• Results: - Group of disorders caused by
Increased: Conjugated bilirubin, infectious, metabolic, toxic or
Urinary bilirubin, ALP, GGT, Total druginduced disease found mostly in
bilirubin, Unconjugated bilirubin children
Decreased: Urine and - Often preceded by viral syndrome
fecal urobilinogen - Related to aspirin consumption during
the viral syndrome - Symptoms:
Profuse vomiting
Neurological impairment
 Cirrhosis
- Scar tissue replaces normal healthy
liver tissue
- As time moves forward, function
deteriorates and signs appear
Fatigue, nausea, weight
loss, jaundice, etc.

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 o Genetic factors o
Nutritional status

ALCOHOLIC INJURY

Stages:

1. Alcoholic Fatty liver

- Mildest form
- Elevations of AST, ALT, GGT
- Complete recovery possible if drug
removed
2. Alcoholic hepatitis
- Moderate elevations of AST, ALT,
- Common causes: GGT
Chronic alcoholism - Bilirubin, ALP also elevated
Hepatitis  Results: - PT prolonged
Increased: unconjugated & conjugated 3. Alcoholic cirrhosis
bilirubin, ALP, GGT, AST, ALT Decreased: - Elevated AST, ALT, GGT, ALP, total
cholesterol, albumin bilirubin
- Albumin decreased
 Drug & Alcohol disorders - PT prolonged
 Accounts for 1/3 to ½ of acute liver failure
since the liver plays a major role in drug  Hepatitis
metabolism
 Inflammation of the liver
 Drugs cause an immune mediated injury to
 Viral, bacterial, radiation, drugs,
the hepatocytes, resulting in disease
chemicals and others can cause
 Ethanol is the most significant alcohol inflammation
 Acetaminophen is also a common drug  Viral infections account for the
 Several stages of classification based on majority of cases in the clinical lab
disease severity  Includes subtypes A, B, C, D and E
ALCOHOLIC LIVER DISEASE  Clinical Symptoms
Jaundice, dark urine,
 Breakdown of alcohol leads to toxin fatigue, nausea,
formation abdominal pain
 Risk factors for ALD include:
o History & magnitude of
alcohol consumption o
Hepatitis B or C
infection
o Gender

. 6
 - Described the reaction of bilirubin
with diazotized sulfanilic acid = DIAZO
REACTION

Malloy and Evelyn (1937)

- Diazo reaction with 50% methanol as

an accelerator

LIVER PANEL
 Albumin  Bilirubin, total
 Bilirubin, direct
 AST/SGOT
 ALT/SGPT
 Alkaline Phosphatase

LFTs are divided into:

 True tests of liver function such as serum

albumin, bilirubin and protime
 Tests that are indicators of liver injury or
biliary tract disease Jendrassik and Grof (1938)

CLASSIFICATION OF LIVER FUNCTIONS TEST - Diazo reaction with caffeinebenzoate-

acetate as accelerator
Classified based on the major functions of liver: - Increased sensitivity
1. Excretion: Measurement of bile pigments, MEASURED VS. CALCULATED
bile salts
2. Serum enzymes: Transaminase (ALT, AST), Measured Analytes
alkaline phosphatase (ALP),
- Total Billirubin
5’nucleotidase, LDH isoenzyme
- Conjugated bilirubin (DIRECT)
3. Synthetic function: Prothrombin time,
serum albumin Calculated Analytes
4. Metabolic capacity: Galactose tolerance
- Unconjugated bilirubin (INDIRECT)
and antipyrine clearance
FRACTIONS & THEIR CHARACTERISTICS
 Conjugated/Direct
HISTORY OF BILIRUBIN ANALYSIS
 Polar
Ehrlich (1883)  Water-soluble

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  Found in plasma, unbound or free - In the PH, carbon paper is used
 Reacts with diazotinized sulfanilic
acid without an
accelerator
 Unconjugated/Indirect
 Nonpolar
 Water-insoluble
 Found in plasma, bound to
albumin
 Reacts with diaotinized sulfanilic
acid with an accelerator
 Delta
 Conjugated bilirubin bound to but Amber-colored
albumin container is most preferred.
 Observed in hepatic Other specimen considerations:
obstructions
 Reacts with diazo reagent in direct  Assay must be carried out within 2 hrs of
assay sample collection, if delayed, refrigerate
 Delta = TB-DB-IB the sample.
 Not calculated in  Point of care direct spectrophotometric
neonatal patients measurement of bilirubin in neonates heel
 Ref value: <0.2 mg/dL prick samples may be taken directly in
hematocrit capillary tubes.
B1 = Total bilirubin – B2 (ref range: 0.2-0.8
mg/dL or 3.4 – 12.0 µmol/L METHODS OF BILIRUBIN ANALYSIS

SPECIMEN COLLECTION AND STORAGE  Jendrassik-Grof

- Measures Total and Conjugated
 Serum or plasma preferred bilirubin
 Temperature sensitive
 Fasting morning sample preferred Principle:
- Lipemia increases - Bilirubin pigments in serum react with
bilirubin concentrations diazo reagent which results in the
 No hemolysis production of azobilirubin (a purple
- Hemolysis decreases the product). Measured @ 540 nm.
reaction of bilirubin with the - Caffeine-benzoate accelerates the
diazo reagent (falsely lower the coupling of bilirubin with the diazo
bilirubin value) reagent.
 Light sensitive - Ascorbic acid stops the reaction
- Bilirubin levels decrease by 30- - Alkaline tartrate converts the purple
50% per hour azobilirubin to a blue azobilirubin.
- This product is measured
spectrophotometrically @ 600 nm.

. 8
 Enzymes
- Liver damage results in the release of
enzymes into the circulation
Advantages:
- Differentiate between functional or
- Not affected by pH changes mechanical causes of disease
- Maintains optical sensitivity at low - Significant enzymes  AST  ALT
bilirubin concentrations  ALP
- Insensitive to high protein  GGT
concentrations  5’ nucleotidase
Urine bilirubin  LDH
 Amino transferases
- presence indicates - ALT and AST rise rapidly in most
conjugated hyperbilirubinemia diseases of the liver and stay elevated
- Detected using urine dipsticks for up to 2-
- Have a diazo reagent imbedded in the 6 weeks
strip - Highest levels seen with hepatitis,
- Follows the Ehrlich principle hepatic ischemia and
- (Chemstrip/Multistix) drug/toxininduced necrosis
- Fresh urine should be used
- Avoid light & oxidation  Phosphatases
- ALP differentiates hepatobiliary disease
Urobilinogen from bone disease
- End product of bilirubin metabolism - 5’ Nucleotidase is elevated in
- Majority excreted in feces, some hepatobiliary disease
reabsorbed and returned to the liver -
Increased:
Hemolytic disease Defective - GGT elevated in biliary obstruction & in
liver-cell function - Decreased: chronic alcoholism
o Biliary obstruction o - LDH/LD serves as a nonspecific marker of
Carcinoma cellular injury
POINTS TO REMEMBER:
Determination of Urobilinogen
Elevated liver enzymes are as easy as ABC:
• Ehrlich’s reaction
• Alcoholism
Ehrlich’s reagent = p-dimethyl
• Biliary Obstruction
aminobenzaldehyde
Urobilinogen + Ehrlich’s reagent = Red • Cirrhosis
color - Performed on fresh urine •
Reference Range: Misc. Liver Function Tests
- 0.1 – 1.0 Ehrlich units in 2 hrs Prothrombin time

- Elevated in liver disease

. 9
 Ammonia - Assess the liver’s ability to metabolize
carbohydrates
- Elevated in liver disease

Glucose/Galactose Tolerance (GGT)

Additional:

Jendrassik-Grof method:

. 10
. 11