Liver Functions, Gastric Functions and Pancreatic Functions Tests

Dr. S. M. A.
Waseem, JNMC, AMU, Aligarh 9/22/2021
Liver Functions, Gastric Functions

and Pancreatic Functions Tests
Dr. S. M. A. Waseem
1 Dr. S. M. A. Waseem, JNMC, AMU, Aligarh
1
Dr. S. M. A. Waseem, JNMC, AMU, Aligarh 9/22/2021
Liver Function Test:

 Jaundice is yellowish discolouration of skin, sclera and
mucus membrane. Characterized by elevation of serum
bilirubin.
 Portal hypertension is increased in portal venous
pressure. There will be decreased metabolic functions of
liver, decrease in albumin will cause decrease oncotic
pressure ultimately leading to ascites, detoxification of
ammonia is effected resulting in hyperammonemia leading
to hepatic encephalopathy.
 Ascites: effusion of serous fluid in the abdominal cavity. If
the serum albumin: ascitic fluid albumin is > 1.1 then the
reason
2
is portal hypertension.
Dr. S. M. A. Waseem, JNMC, AMU, Aligarh
2
Liver function defect and damage to hepatocytes
Increased resistance to blood flow
Decrease albumin, decrease in colloid oncotic pressure, there is oozing of

fluid in intraperitoneum
Decrease in central blood pressure
Decrease in renal perfusion leading to activation of RAAS, thereby causing

retention of salt and water
ascites
3
Bilirubin Direct(conjugated)=0.1 to 0.4, obstructive jaundice

0.2 to 0.8 Indirect (unconjugated)=0.2 to 0.7 (color is produced when alcohol is
mgm/dl added), haemolytic jaundice
Biphasic when there is hepatocellular jaundice
>2mgm/dl is jaundice
Bilirubin is estimated by Van der Berg reaction(sulfanilic acid in HCL
and sodium nitrite reacts with bilirubin to form azobilirubin which is
purple colored)
Urinary bilirubin Conjugated bilirubin is water soluble and is thus excreted in urine
Fouchet’s test Obstructive jaundice: urinary bilirubin is positive
Prehepatic jaundice is unconjugated thus bilirubin is absent in
urine
Urinary Obstructive jaundice: bile is not reaching the intestine thus
urobilinogen urobilinogen is absent or decreased in urine.
Ehrlichs test Haemolytic anemias= urobilinogen is increased in urine
Bile salts in Obstruction in biliary passage cause the regurgitation of the bile salts
urine in the systemic circulation and excretion in urine
Hays test
4
Tests of Serum: Total Bilirubin, Conjugated and Unconjugated Bilirubin

liver Urinary: Bile Salts, Urobilins, Urobilinogen
excretory
functions
Liver ALT (alanine amino transferase): elevated more in heptic diseases

enzymes AST (aspartate amino transferase)
Markers of ALP (alkaline phosphatase): hepatic carcinoma and cholestasis
liver injury GGT(gamma glutamyl transferase): alcoholic liver disease
and AST/ALT > 2 = Alcoholic liver disease
cholestasis
Plasma Total proteins

proteins A/G ratio(Albumin/ globulin): albumin is decreased in cirrhosis
Normal albumin is 3.5-5 gm/dl
Globulin is 2.5-3. 5 gm/dl
Gamma globulins are increased in chronic liver disease
Prothrombin time elevated in chronic liver disease and Vit K deficiency
(3,7,9,10) gamma carboxylation
5
Others Ceruloplasmin serum reduced and copper in urine elevated

LDH is increased in in wilson’s disease
ischemic/hypoxic hepatitis Ferritin increased in hemchromatosis
and cancers that infiltrate the Alhpa 1 Anti Trypsin : neutrophil elastase
liver Alpha Feto Protein: mild elevation in chronic hepatistis and
cirrhosis, marked in hepatocellular cancer
Markers of hepatocellular ALT and AST leak from damaged cells and are markedly
injury elevated in acute viral hepatitis, drug/ toxins hepatitis,
ischemic/hypoxic hepatitis.
Acute liver failure: fall to normal, along with incresaed
bilirubin, PT and INR
MILD increase in: NAFLD, cirrhosis, alcohol liver disease,
alcohol hepatitis
Markers of cholestasis ALP (placenta, small intestine, kidney,WBC and bone)
GGT
Blood Ammonia When indicated. Elevated in hepatic encephalopathy
Ig G Chronic hepatitis, alcohol hepatitis and autoimmune hepatitis
Ig M Primary biliary cirrhosis, and moderate increased in viral

hepatitis and cirrhosis
Ig A 6 Alcoholic and primary biliary cirrhosis
Dr. S. M. A. Waseem, JNMC, AMU, Aligarh
6
PT and INR:
 PT may be expressed in time (seconds) or, preferably, as a ratio of the patient’s
measured PT to the laboratory’s control value (INR).
 The INR is more accurate than PT for monitoring anticoagulation.
 PT or INR is a valuable measure of the liver’s ability to synthesize fibrinogen and
vitamin K–dependent clotting factors: factors II (prothrombin),VII, IX, and X.
 Changes can occur rapidly because some of the involved clotting factors have short
biologic half-lives (eg, 6 hours for factor VII).
 Abnormalities indicate severe hepatocellular dysfunction, an ominous sign in acute liver
disorders.
 In chronic liver disorders, an increasing PT or INR indicates progression to liver
failure.
 The PT or INR does not increase in mild hepatocellular dysfunction and is often
normal in cirrhosis.
 A prolonged PT and an abnormal INR can result from coagulation disorders such as
a consumption coagulopathy or vitamin K deficiency.
 Fat malabsorption, including cholestasis, can cause vitamin K deficiency.
 In chronic cholestasis, marked hepatocellular dysfunction can be ruled out if vitamin K
replacement (10 mg subcutaneously) corrects PT by≥ 30% within 24 hours.
7
8
9
Indications:
 Suspected liver metastasis

 Jaundice
 Alcoholic liver disease
 Chronic illness
 Diabetics
 Coagulation disorders
 Hepatotoxicity
10
Bilirubin Jaundice Causes
Unconjugated Prehepatic or haemolytic Abnormal RBC, drugs, thalassemias,

hemoglobinopathies, Gilbert’s and
Crigler Najjar syndrome
Unconjugated Hepatic or hepatocellular Viral hepatitis, toxic hepatitis

and conjugated
Conjugated Obstructive/surgical/post Carcinoma head of pancreas, gall

hepatic stones, lymph node enlargement in
the porta heaptis
11
speci tests prehepatic hepatocellular posthepatic

men
Blood Unconjugated bilirubin ++ ++ N
Conjugated bilirubin N In early phase it is ++

increased
Alkaline phosphatase N 2-3 times elevated 10-12 times
Urine Bile salts - - Present
Conjugated bilirubin - present Present
urobilinogen +++ Presence is early Absent

manifestation of
recovery
feces urobilins ++ Normal or Clay colored
decreased stools
12
BSP, Bromsulphalein Test
 This is a liver function test used to diagnose general liver

disfunction, including obstructive liver disease.
Clinical Implications:
 This test uses an injected dye, BSP, for diagnosis of liver
disease. After the injection, several blood samples are
taken to determine the blood level of the dye. These
levels will indicate the liver's ability to excrete the dye
and thus the general functioning of the liver. This test is
very diagnostic of inactive cirrhosis of the liver.
13
GASTRIC FUNCTION TESTS:
 Important points to remember:

 Mechanism and regulation (gastrin, histamine and
prostaglandins) of gastric acid secretions
 Daily around 2l is secreted
 P H is 0.8
 Alkaline tide
14
Assessment of gastric functions:

Fractional test The fasting stomach contents are aspirated and the secretions are
meal stimulated by giving test meals. Not done nowadays but other tests
are done.
Pentagastrin The gastric contents are aspirated through ryle’s tube.

stimulation test Basal secretion of 1 hour is collected
Synthetic peptide pentagastrin is given
Gastric secretions are collected every 15 minutes for 1 hour
BAO is basal output in milli mol/hour
MAO (millimole/hour) : sum of 4x 15 minutes
PA0(millimole/hour) sum of acid output of 2 consecutive 15 minutes
samples having the highest acid content.
ZES Gastrin secreting tumor

BAO> 15, BAO/PAO>0.3
Chronic BAO, MAO, PAO are elevated. BAO> 4-6, BAO/PAO>0.3

duodenal ulcer
H. Pylori Urease enzymes in gastric biopsy
H.Pylori antibodies in serum
15
16
Pancreatic Function Test:
 1 to 2.5 l/day
 Alkaline, rich in bicarbonate and enzymes
 CCK role
 Secretin role
 Regulation and phases of secretions
 Major enzymes and functions
17
Serum amylase 50-120 units is normal serum levels

In acute pancreatitis level rises in 5 hours and reach peak
within 12 hours
Within 2-4 days the levels may reach normal limits
Mildly elevated in cholecystitis
Serum lipase Blood levels are elevated in acute pancreatitis and persist
for 1-2 weeks.
Lipase is not increased in salivary diseases
Lundh test 500 ml Test meal (6% fat, 5% protein and 15% CHO ) is
given after aspirating the duodenal contents.
Duodenal secretions are collected at 30 minutes interval
for 2 hours.
The tryptic activity is decreased in chronic pancreatitis but
not in carcinoma of pancreas
Steatorrhea Fat in stool is suggestive of fat malabsorption
18
Laboratory Time of Purpose Clinical observation/limitations

test onset
(hours)
Alanine 12-24 Diagnosis and Associated with gallstone pancreatitis;
transaminase etiology threefold elevation or greater in the
presence of acute pancreatitis has a positive
predictive value of 95 percent in diagnosing
acute gallstone pancreatitis
Amylase 2-12 Diagnosis Most accurate when at least twice the

upper limit of normal; amylase levels and
sensitivity decrease with time from onset of
symptoms
C-reactive 24-28 Predictive of Late marker; high levels associated with

protein severity pancreatic necrosis
19
Lipase 4-8 Diagnosis increased sensitivity in

alcohol-induced pancreatitis;
more specific and sensitive
than amylase for detecting
acute pancreatitis
Phospholipase A2 24 Predictive of severity Associated with development of
pancreatic necrosis and
pulmonary failure
Procalcitonin 24-36 Predictive of severity Early detection of severity' high
concentration in infected
necrosis
Trypsinogin Within a few Diagnosis and Early marker for acute
activation peptide hours predictive of severity pancreatitis and close correlation
to severity
Interleukin-6 18-48 Predictive of severity Early indication of severity

Interleukin-8 12-24 Predictive of severity Early indication of severity
20
MRI In patients with contraindication with CT with contrast.

can also identify the presence of necrosis.
Transabdominal is used to examine the gallbladder and cystic duct when the
ultrasound presence of gallstones is suspected, which is a leading cause of this
disorder
Endoscopic help indentify less common causes of pancreatitis, such as

Retrograde microlithiasis, sphincter of Oddi dysfunction and pancreatic duct
Cholangiopancre strictures. ERCP should be immediately performed on patients at
atography risk for biliary sepsis, severe pancreatitis with biliary obstruction,
(ERCP) cholangitis, elevated bilirubin, worsening and persistent jaundice, or
signs of worsening pain during an abnormal ultrasound examination.
As these patients may require immediate surgical or
gastroenterologic intervention.
Magnetic noninvasive technique that can be used preoperatively to determine

resonance which patients may benefit from ERCP. MRCP is as accurate as
cholangiopancre contrast-enhanced CT in predicting the severity of pancreatitis and
atography identifying pancreatic necrosis, can assess pancreatic and
(MRCP) peripancreatic cysts, and useful when ERCP is not possible or is
unsuccessful.
21
http://www.differencebetween.net/science/health/difference-between-ercp-and-
mrcp/
22
Endoscopic identify stones and tumors, but less frequently than

ultrasonography (EUS ERCP. Nevertheless, it is useful in obese patients and
patients with ileus, and can help determine which
patients with acute pancreatitis are the best
candidates for therapeutic ERCP.
Ranson criteria
Acute Physiology and Chronic Health Evaluation score (APACHE II)
23
Gall stones:
 Mixed stones (10%) are easily seen on plain film secondary to

calcifications . USG acoustic shadow.
 Female, middle aged , fat, fertile , fourty
 Gall bladder stores bile salts
 Gall stones occur when the solutes in the gall bladder
precipitate
 Cholestrol stones are yellow green and account for 80%
stones
 Bilirubin stones are dark in color
 Pain after fatty meals, epigastric/right upper quadrant radiating
to right shoulder.
 If gall bladder is inflammed or infected then cholecytitis occurs
 Stones can obstruct bile duct or may result in pancreatitis.
24
(A-D) Cholesterol stones.

(E) Brown pigment stones.
(F) Black pigment stones.
https://www.uptodate.com/contents/image?imageKey=GAST%2F114842&to
picKey=PI%2F4578&source=see_link
25
References:
http://medicalfarre.in/gastric-pancreatic-exocrine-liver-function-tests/
https://www.msdmanuals.com/en-in/professional/hepatic-and-biliary disorders/testing-for-
hepatic-and-biliary-disorders/laboratory-tests-of-the-liver-and-gallbladder
https://www.physio-pedia.com/Pancreatitis
https://www.nurseslearning.com/courses/nrp/labtest/course/section6/index.htm
uptodate
26

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Dr. S. M. A.

Waseem, JNMC, AMU, Aligarh 9/22/2021

Liver Functions, Gastric Functions

1 Dr. S. M. A. Waseem, JNMC, AMU, Aligarh

Liver Function Test:

Liver function defect and damage to hepatocytes

Increased resistance to blood flow

Decrease albumin, decrease in colloid oncotic pressure, there is oozing of

Decrease in central blood pressure

Decrease in renal perfusion leading to activation of RAAS, thereby causing

Bilirubin Direct(conjugated)=0.1 to 0.4, obstructive jaundice

Tests of Serum: Total Bilirubin, Conjugated and Unconjugated Bilirubin

Liver ALT (alanine amino transferase): elevated more in heptic diseases

Plasma Total proteins

5 Dr. S. M. A. Waseem, JNMC, AMU, Aligarh

Others Ceruloplasmin serum reduced and copper in urine elevated

Ig M Primary biliary cirrhosis, and moderate increased in viral

7 Dr. S. M. A. Waseem, JNMC, AMU, Aligarh

8 Dr. S. M. A. Waseem, JNMC, AMU, Aligarh

9 Dr. S. M. A. Waseem, JNMC, AMU, Aligarh

 Suspected liver metastasis

10 Dr. S. M. A. Waseem, JNMC, AMU, Aligarh

Bilirubin Jaundice Causes

Unconjugated Prehepatic or haemolytic Abnormal RBC, drugs, thalassemias,

Unconjugated Hepatic or hepatocellular Viral hepatitis, toxic hepatitis

Conjugated Obstructive/surgical/post Carcinoma head of pancreas, gall

11 Dr. S. M. A. Waseem, JNMC, AMU, Aligarh

speci tests prehepatic hepatocellular posthepatic

Blood Unconjugated bilirubin ++ ++ N

Conjugated bilirubin N In early phase it is ++

Urine Bile salts - - Present

Conjugated bilirubin - present Present

urobilinogen +++ Presence is early Absent

BSP, Bromsulphalein Test

 This is a liver function test used to diagnose general liver

13 Dr. S. M. A. Waseem, JNMC, AMU, Aligarh

GASTRIC FUNCTION TESTS:

 Important points to remember:

14 Dr. S. M. A. Waseem, JNMC, AMU, Aligarh

Assessment of gastric functions:

Pentagastrin The gastric contents are aspirated through ryle’s tube.

ZES Gastrin secreting tumor

Chronic BAO, MAO, PAO are elevated. BAO> 4-6, BAO/PAO>0.3

16 Dr. S. M. A. Waseem, JNMC, AMU, Aligarh

Pancreatic Function Test:

17 Dr. S. M. A. Waseem, JNMC, AMU, Aligarh

Serum amylase 50-120 units is normal serum levels

Steatorrhea Fat in stool is suggestive of fat malabsorption

18 Dr. S. M. A. Waseem, JNMC, AMU, Aligarh

Laboratory Time of Purpose Clinical observation/limitations

Amylase 2-12 Diagnosis Most accurate when at least twice the

C-reactive 24-28 Predictive of Late marker; high levels associated with

19 Dr. S. M. A. Waseem, JNMC, AMU, Aligarh

Lipase 4-8 Diagnosis increased sensitivity in

Interleukin-6 18-48 Predictive of severity Early indication of severity

20 Dr. S. M. A. Waseem, JNMC, AMU, Aligarh

MRI In patients with contraindication with CT with contrast.

Endoscopic help indentify less common causes of pancreatitis, such as

Magnetic noninvasive technique that can be used preoperatively to determine

22 Dr. S. M. A. Waseem, JNMC, AMU, Aligarh

Endoscopic identify stones and tumors, but less frequently than

Acute Physiology and Chronic Health Evaluation score (APACHE II)