Pharmacy Skills

37960

Review of Laboratory
and Diagnostic Tests
Lecture 7
Dr Rabab Hamed

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GASTROINTESTINAL SYSTEM
LABORATORY TESTS

• Bilirubin is useful in the diagnosis and monitoring of liver disease

and hemolytic anemia and in the assessment of the severity of
jaundice. A patient is generally visibly jaundiced if the bilirubin level
is higher than 2 mg/dL.

• Alkaline phosphatase level is elevated in biliary cirrhosis,

cirrhosis, and intrahepatic bile duct disease.

• Direct bilirubin is water-soluble conjugated posthepatic bilirubin. It

is increased in biliary disease (e.g., extrahepatic bile duct
obstruction, physical impairment of bile flow, impaired bile
transport) and some liver disease (e.g., hepatitis, cirrhosis, hepatic
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neoplasm).
GASTROINTESTINAL SYSTEM
LABORATORY TESTS

• Indirect bilirubin is unconjugated bilirubin. Its level is increased in

hemolytic anemia (rapid, severe hemolysis) and some liver
disease.

• Many drugs are metabolized hepatically. One way of assessing the

liver’s ability to metabolize these agents is to assess the synthetic
function of the liver by evaluating the quantity of specific products
produced or processed by the liver. These include ammonia,
albumin, and the vitamin K–dependent clotting factors.

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GASTROINTESTINAL SYSTEM
LABORATORY TESTS

• Serum ammonia level is increased if the liver is damaged or if

blood flow is compromised. Although serum ammonia level is not
used as a routine screening test, it is sometimes performed to
confirm a diagnosis of hepatic encephalopathy.

• The serum levels of albumin and the vitamin K–dependent

clotting factors are commonly used to assess hepatic synthetic
function.

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GASTROINTESTINAL SYSTEM
LABORATORY TESTS

• Vitamin K–dependent clotting factors (factors II, VII, IX, and X).
Lack of production of the vitamin K–dependent clotting factors
prolongs the prothrombin time (PT) and activated partial
thromboplastin time (aPTT). The PT is prolonged earlier than the
aPTT and often is used as an early indicator of impaired hepatic
synthetic function. Both the PT and aPTT are prolonged in
longstanding severe hepatic dysfunction.

• Alanine aminotransferase (ALT) is found in high concentrations in

hepatocytes and is considered a specific marker of hepatocellular
damage
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GASTROINTESTINAL SYSTEM
LABORATORY TESTS

• Aspartate aminotransferase (AST) is found in hepatocytes,

myocardial muscles, skeletal muscle, the brain, and the kidneys. It
is used as a nonspecific marker of hepatocellular damage.

• Gamma glutamyl transpeptidase (GGT) is found in hepatobiliary,

pancreatic, and kidney cells. It is elevated in most hepatocellular
and hepatobiliary disease, although elevations correlate better with
obstructive disease than with pure hepatocellular damage. An
elevated GGT level is an early indicator of alcoholic liver disease.

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GASTROINTESTINAL SYSTEM
LABORATORY TESTS

• The stool is evaluated for color, consistency, and the presence of

obvious or occult blood, fat, ova and parasites, microorganisms,
and white blood cells (WBCs).

• The color of the stool provides important diagnostic and monitoring

information.

• Black stools may indicate upper gastrointestinal tract bleeding;

however, iron therapy may produce a similar color.

• Gray stools are generally associated with steatorrhea; light gray

stools may indicate bile duct obstruction
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GASTROINTESTINAL SYSTEM
LABORATORY TESTS

• Watery stools are indicative of rapid gastrointestinal tract transit

and malabsorption syndromes.

• Hard stools may indicate dehydration.

• The presence of obvious blood in the stool indicates colonic

bleeding

• Occult blood, present in both upper and lower gastrointestinal tract

bleeding, may be detected for several weeks after gastrointestinal
tract bleeding.
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GASTROINTESTINAL SYSTEM
LABORATORY TESTS

• Stool fat is increased in diseases associated with altered bacterial flora,

increased gastrointestinal tract motility, decreased enzyme and bile acid
content.

• The presence of WBCs is associated with a variety of infectious processes

and inflammatory bowel disease.

• Alpha fetoprotein is the major protein produced by the fetus in the first 10
weeks of life. It also is produced by rapidly multiplying hepatocytes and is
used as a marker of hepatocellular carcinoma.

• Carcinoembryonic antigen (CEA) is a tumor marker found in the blood. It is

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associated with rapid multiplication of digestive system epithelial cells and is
used to monitor tumor recurrence.
GASTROINTESTINAL SYSTEM
DIAGNOSTIC TESTS AND PROCEDURES

• The abdominal radiograph, including the kidneys, ureter, and bladder

(KUB), is obtained with the patient lying supine and is used to identify
intestinal obstruction and other organ-specific structural abnormalities.

• Abdominal paracentesis )‫ (بذل‬is used to obtain ascitic fluid for analysis. The
fluid is assessed for each of the following characteristics:
1. Color. Ascitic fluid may be yellow in cirrhosis, cloudy in infection, brown in
hyperbilirubinemia, or bloody in malignancy.
2. Cell count. A polymorphonuclear cell count of 250/mm3 or more indicates
infection.

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GASTROINTESTINAL SYSTEM
DIAGNOSTIC TESTS AND PROCEDURES

• In barium studies the patient swallows contrast

material, such as barium sulfate, and radiographs are
taken to visualize the esophagus, stomach, and small
intestine.

• Barium enemas are used to visualize the large

intestine. The double-contrast barium enema technique
uses a combination of barium and air to visualize the
large intestine and is considered a more precise
procedure.

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GASTROINTESTINAL SYSTEM
DIAGNOSTIC TESTS AND PROCEDURES

• Capsule endoscopy is a relatively new

method used to visualize the gastrointestinal
tract. The patient swallows a disposable
capsule about the size of a large vitamin
tablet that contains a miniature video camera,
a light source, a miniature transmitter,
antenna, and battery. Images are transmitted
to an external receiver in a belt worn around
the patient’s waist. Peristalsis moves the
capsule through the gastrointestinal tract; the
capsule is excreted rectally.
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GASTROINTESTINAL SYSTEM
DIAGNOSTIC TESTS AND PROCEDURES

• Cholecystography is used to evaluate gallbladder function and

anatomy. Orally administered iopanoic acid concentrates in the
gallbladder, opacifying it for visualization.

• Cholecystosonography is used to detect gallstones and evaluate

the gallbladder, biliary system, and adjacent organs. Sonography
has nearly replaced cholecystography.

• In endoscopy a flexible fiberoptic tube is inserted orally into the

esophagus to visualize the lining of the upper and lower
gastrointestinal tract.
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GASTROINTESTINAL SYSTEM
DIAGNOSTIC TESTS AND PROCEDURES

• The d-xylose test is used to screen for carbohydrate

malabsorption.

• For this test a dose of 25 g of d-xylose is administered with water,

and the urine is collected for a 5-hour period. Normally, more than 3
g of d-xylose is excreted in the urine during this period; lower
amounts indicate impaired carbohydrate absorption.

• The pH of gastric secretions is sometimes measured to monitor

the effectiveness of acid-suppressive drug therapy or to document
the presence and severity of acid reflux.
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RESPIRATORY SYSTEM
LABORATORY TESTS

• Arterial Blood Gases analysis is used to assess the acid-base

balance and level of ventilation, to diagnose acid-base
disturbances, and to monitor patient response to drug and nondrug
interventions.

• Carboxyhemoglobin forms in the presence of carbon monoxide

(e.g., exposure to smoky house fires, exposure to car exhaust
fumes). Carbon monoxide has a greater affinity for hemoglobin
receptors than does oxygen, preferentially binding to the receptors
and preventing the RBCs from binding and transporting oxygen.
The level of carboxyhemoglobin, normally present in very small
quantities in nonsmokers, may be elevated in smokers.
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RESPIRATORY SYSTEM
LABORATORY TESTS

• Venous blood gas analysis sometimes is used in place of ABG

analysis to assess the level of ventilation and to monitor patient
response to drug and nondrug interventions.

• Sputum analysis is used to screen for disease and to monitor

patient response to drug and nondrug therapy. It consists of
macroscopic and microscopic assessments of the sputum.

• Mucus is normally mucoid and clear. Purulent )‫ (صديدى‬sputum

contains pus and is associated with bacterial infection. Yellow
sputum is indicative of inflammation. Uniformly rusty-appearing
purulent sputum is indicative of pneumococcal (Streptococcus
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pneumoniae) pneumonia.
RESPIRATORY SYSTEM
LABORATORY TESTS

• Bright red streaks in viscid sputum are indicative of Klebsiella

pneumoniae pneumonia. Greenish black sputum is indicative of
infection with gram-negative bacilli.

• Normal sputum is odorless. Foul-smelling sputum is indicative of a

bacterial infection.

• Normal sputum is thin and watery. Patients with asthma have a

very thick, sticky, sputum.

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RESPIRATORY SYSTEM
DIAGNOSTIC TESTS AND PROCEDURES

• Bronchoscopy is used to visualize the tracheobronchial tree.

Samples of fluid and tissue may be obtained for Gram staining,
culture, and cytologic examination.

• Chest radiographs aid in the diagnosis of pulmonary and cardiac

disease and the assessment of patient response to drug and
nondrug interventions.

• Thoracocentesis is the procedure that is used to obtain a sample of

pleural fluid for analysis

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RESPIRATORY SYSTEM
DIAGNOSTIC TESTS AND PROCEDURES

• Pulmonary function testing is used to diagnose pulmonary

disease, to monitor progression of disease, to predict response to
bronchodilators, and to monitor patient response to drug and
nondrug therapy.

• Pulmonary function testing is performed using spirometry.

• A spirometer detects and records changes in lung volume and flow.

Normal values vary with age, gender, height, and weight. In
general, decreases of 20% or more from predicted values are
considered significant.
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BIOMARKERS

• Biomarker is “a characteristic that is measured and evaluated

as an indicator of normal biologic processes, pathogenic
processes, or pharmacologic response to a therapeutic
intervention

• Proximal biomarker: biomarker that occurs early in the

pathophysiologic cascade

• Distal biomarker: biomarker that occurs late in the

pathophysiologic cascade

• Preventive biomarker: biomarker that prospectively identifies risk

of disease 20
BIOMARKERS

• Diagnostic biomarker: biomarker that identifies the disease

before any clinical signs or symptoms appear

• Prognostic biomarker: biomarker that stratifies the risk of disease

progression

• Predictive biomarker: biomarker that prospectively identifies

patient response to therapy

• Surrogate end point biomarker: biomarker that substitutes for a

clinical end point

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BIOMARKERS

• PHARMACOGENETIC BIOMARKERS: Assessment of pharmacogenetic

biomarkers is important for optimizing individual drug therapy (e.g., cetuximab
is selectively effective against breast cancer tumors that overexpress EGFR)
and avoiding rare but important drug toxicities (e.g., patients with a
homozygous TPMT variant are at a higher risk of azathioprine-associated
granulocytopenia).

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BIOMARKERS

• CARDIAC BIOMARKERS

• Atrial natriuretic peptide (ANP) and brain natriuretic peptide (BNP): ANP
and BNP, secreted by the heart, regulate blood pressure and body fluid
balance by antagonizing the renin-angiotensin-aldosterone system and the
sympathetic nervous system.

• C-reactive protein (CRP): CRP, a protein synthesized by the liver in

response to cytokine stimulation, reflects ongoing inflammation and is
predictive of increased risk of acute myocardial infarction.

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BIOMARKERS

• CANCER BIOMARKERS

• BRCA1 and BRCA2 gene mutations are used as screening markers to

identify patients at increased risk for developing breast and ovarian cancer.

• Biomarkers that are overexpressed by tumors and detectable in the serum

include CEA for colorectal cancer, alpha fetoprotein for primary liver
carcinoma, prostate-specific antigen (PSA) for prostate cancer, cancer
antigen 125 (CA125) for ovarian carcinoma, and cancer antigen 19-1 (CA19-
9) for pancreatic and gastric carcinomas.

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BIOMARKERS

• Alzheimer’s Disease

• CSF levels of tau proteins may be useful for identifying patients with mild
cognitive impairment that may progress to Alzheimer’s disease.

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