Lecture 5: Laboratory exploration in gastrointestinal pathology

2011-2012

Content of lecture 5:
A. Liver exploration:

tests indicating an inflammatory process; tests indicating liver cytolysis, tests indicating synthesis of proteins, tests indicating cholestasis. Features of bilirubin metabolism.

B. Pancreas exploration. C. Gastrointestinal exploration.

A. Liver exploration

Liver function.

Role of the liver in: -proteic synthesis -carbohydrates metabolism -lipid metabolism -biliary secretion -coagulation and fibrinolysis -inactivation of some hormones -detoxification (metabolites, drugs) Morphopathological lesions in the liver -a. Inflammation -b. necrosis -c. fibrosis -d. steatosis -e. cholestasis -f. tumoral procesess

a. Tests indicating an inflammatory process

Tests indicating an interstitial inflammation plasmocytes

infiltration Ig synthesis gamma globulines Chronic Hepatitis Ig G Biliary cirrhosis- Ig M Alcoholic Hepatopathy- IgA Positive tests for disproteinemia (Takata, Tymol, sulfat de Zn)

Causes: Rubella, CMV, Epstein Barr Chemical poisoning Chloroform, Pyrimidifen Hepatitis (A,-B,-C,-D,-E) Toxic mushrooms Yellow fever Gallstones Porphyria Cutanea Tarda Alcoholic hepatitis

b. Tests indicating liver cytolysis

Tests indicating increase of cell permeability ASAT, ALAT intracellular LDH 4,5 OCT(ornithine carbamoyltransferase), SDH (succinate dehydrogenase), ICDH (isocitrate dehydrogenase) Degree of increase depends on: nr. of involved cells Cell damage Vascularisation of the damaged tissue Existance of an inflammatory barrier Half-life time of the enzyme Viral acute hepatitis increases of 10-50x; ALAT especially Chronic hepatitis- increases in range of 5-20x - stabil increases- 2-3x; - acute - increase of ASAT Alcoholic Hepatopathy 5-10 x, especially ASAT Liver cirrhosis uncompensated parenchymal normal values or slight increase Tumoral processess- slight increase only; more ASAT (necrotic lesions) Acute Necrosis (intoxication with fungus, organophosphoric solvents)- high increase 100x

c. Tests indicating synthesis of proteins

Tests that evaluate the proteic synthesis of proteines Albumines Not useful in acute liver insuficiency In liver cirrhosis with ascites, part of albumines pass in ascitic fluid (than they decrease in blood) Colinesterase (Che) Broad interval for individual values; one determination is not relevant Decrease of Che reveals a decreased hepatic proteosynthesis -decreased values may appear in severe anemia
malnutrition, malabsorbtion acute phase reaction Hypothiroidism intoxication with organophosphorics

-increased values may appear in abdominal type of obesity HLP type IIb, IV, V nephrotic syndrome hyperthiroidism

Prothrombin time (PT) or Quick time (QT)- (fVII) T/2 short 6-8 hours. useful in acute liver insufficiency.

d. Tests indicating cholestasis

ALP (Alkaline phosphatase) Serum bile acids- sensitive test of hepatobiliary

disease GGT (Gamma glutamyl transpherase)

Biliary obstruction Hepatocellular damage Elevated serum levels occur in: alcohol, phenobarbitone, phenytoin, rifampicin

5Nt (5 nucleotidasis) Biliary obstruction Unlike GGT is not affected by enzyme inducing agents

e. Test indicating liver fibrosis - Fibrotest

FibroTest, known as FibroSure in the US, is a patented biomarker

test that uses the results of six blood serum tests to generate a score that is correlated with the degree of liver damage in people with a variety of liver diseases. FibroTest has the same prognostic value as a liver biopsy. FibroTest has been evaluated in relation to liver biopsy (the current gold standard in liver disease assessment) in a large number of patients with hepatitis C, hepatitis B, alcoholic liver disease, Non-alcoholic fatty liver disease and in the general population. By 2008 it had been used in over 350,000 patients. FibroTest has been validated for the initial diagnosis of fibrosis In 2006, the French National Authority for Health recommended the use of FibroTest as a first-line assessment tool for fibrosis with untreated chronic hepatitis C.

FibroTest score
The FibroTest score is calculated from the results of a six-parameter blood test: Alpha-2-macroglobulin, Haptoglobin, Apolipoprotein A1, Gamma-glutamyl transpeptidase (GGT), Total bilirubin, and Alanine transaminase (ALT). ALT is used in a second assessment called ActiTest that is part of FibroTest.
The FibroTest score (in this case 0.88) may indicate the presence of cirrhosis.

FibroTest derivatives

Four other tests derive from FibroTest, and are part of the

FibroMax package of tests: ActiTest: diagnostic of necrotico-inflammatory for hepatitis; SteaoTest: diagnostic for liver steatosis; NashTest: diagnostic for NASH (Non-alcoholic fatty liver disease) inflammation; AshTest: diagnostic for Alcoholic liver disease inflammation.

The tests are not applicable in 1 to 5% of cases.

Acute hepatitis- e.g., acute viral hepatitis A, B, C, D, E; drug-induced

hepatitis Extrahepatic cholestasis, e.g., pancreatic cancer, gallstones Severe hemolysis, e.g. Gilbert's syndrome with high unconjugated hyperbilirubinemia Acute inflammatory syndrome (the blood test may be postponed)

f. Specific tests that are modified in hepatic diseases

Hematological: Target cells (hepatic disease), megalocytes (alcohol), hemolysis Prothrombin time (PT) and activated partial thromboplastin time (APTT):

PT is testing extrinsec pathway Sintrom, Trombostop treatment APTT testing intrinsec pathway (VIII; IX;XI;XII) Heparin treatment

Antibody titres: Mithocondrial Ab primary biliary cirrhosis Antinuclear factor+ Smooth muscle Ab- autoimmune disease of liver and bilary channels

Antigens and Antibodies for viral hepatitis: Ab HVA, Ag HBs, Ag Hbe, Ab Hbe, Ab HBs, Ab HVC, C viremia

g. Tests indicating specific disorders affecting the liver

Wilson disease

Serum copper and ceruloplasmin Urinary copper Serum iron and total iron binding capacity Serum ferritin Serum alpha-1 antitrypsin Alpha fetoprotein

Hemocromatosis

Alpha-1 antitrypsin deficiency

Primary liver cell cancer

Jaundice

2011-2012

EXTRAVASCULAR DEGRADATION OF HEM

Eritrocitul n circulaie 120 zile

(Liver, Bone marrow, & Spleen)

Phagocytosis & Lysis

Eritrocitele mbtrnite sunt fagocitate sau lizate Liza celulelor are loc intravascular sau extravascular (sistemul reticulohistiocitar)

Hemoglobin

Globin

Heme Fe2+

Bilirubin

Amino acids

Amino acid pool

Excreted

FATE OF INTRAVASCULAR HEMOGLOBIN

Haptoglobin: hemoglobin-haptoglobin complex is metabolized in the

liver and spleen, forming a complex iron-globin that prevents the loss of iron through urine.

Hemopexin: binds the free HEM. The complex hem- hemopexin is

overtaken by the liver, iron being deposited in the form of ferritin.

Methemalbumin: oxidized hem-albumin complex.

METABOLISMUL NORMAL AL BILIRUBINEI

Preluarea bilirubinei (indirecte, neconjugate) de ctre ficat este mediat de o protein ligandin. Bilirubina se conjug cu acidul glucuronic, xiloz, sau riboz. Acidul glucuronic este majoritar reacia e catalizat de UDP glucuronil transferaz. (rezult bilirubina direct, conjugat). Bilirubina conjugat este hidrosolubil, secretat de hepatocite la polul biliar n canaliculele biliare. n intestin este convertit la stercobilinogen (urobilinogen) (incolor) de ctre flora microbian. Oxidarea la stercobilin (colorat

HYPERBILIRUBINEMIA

Jaundice: Total Bilirubin > 3 mg/dL)

PREHEPATIC JAUNDICE

Excess of unconjugated bilirubin (above the liver capacity to conjugate bilirubin) - after hemolysis. Excess of hemolysis: -autoimune diseases, -Hemolytic diseases of newborn (Rh, ABO group incompatibility) -Abnormal RBC (talasemie), - large, extended hematomas. Unconjugated bilirubin < 0.5 mg/dL

HEPATOCELLULAR JAUNDICE

deficit of :

Uptake, conjugation, secretion of bilirubin.

Reflects generalized hepatic disfunction In this case hiperbilirubinemia is associated with increase of other hepatic markers: AST, ALT.

POSTHEPATIC JAUDICE

Caused by obstruction of biliary canaliculs Bilirubina is conjugated, other biliary metabolites biliary acids increase in plasma Stools are weak colored, characterized by the absence of stercobilin and urobilin and dark urine (conjugated bilirubin). In complete obstruction urobilin is absent in urine.

JAUNDICE

BIL I

BIL D N N N

BIL Urin

FA N N N N/

ASAT N N N

Alb N N N N N N DECR EASE N

GGT N N N

JAUNDICE------Bilirubin In urine? YES HEPATOCELLULAR DAMAGE POSTHEPATIC CHOLESTASIS INTRAHEPATIC CHOLESTASIS SDR. ROTOR/ DUBIN-JOHNSON

Physiological jaundice Hemolysis Gilbert syndrome

+ + + ++ +
N

+ + + +

NO:

PHYSIOLOGICAL JAUNDICE

Hepatitis SDR. GILBERT HEMOLYSIS Hepatitis - colestatic GLUCURONIL- TRANSFERASE DEFICIENCY Ciroz - incipienta Ciroz finala Icter obstructiv

++ +++
N

+++ ++
N

++ ++ + ++ +++

++
N

++ +

++ +++

++ +++

++
N/

Genetic diseases in connection with bilirubin metabolism:

1. Gilbert syndrome

uptake deficiency of indirect bilirubin - increased indirect bilirubin - Normal hepatic function, including gamma GT - bilirubin negative in urine 2. Glucuronil transferase deficiency - rare - unconjugated bilirubin (indirect) is increased - bilirubin negative in urine - apear usually in newborns - severe forms known under name Crigler-Najar syndrome 3. Dubin-Johnson and Rotor syndromes - rare - Causes: decreased excretion of direct bilirubin from hepatocytes to biliary canaliculs. Result:hyperbilirubinemia conjugated and positive bilirubine in urine. - in Dubin-Johnson syndrome accumulation of a black pigment in the hepatocytes

NEONATAL JAUNDICE

Apears more frequently in premature newborn Appears in the first 10 days of life, usually in the 4th or 5th day Causes: enzymatic immaturity involved in bilirubin conjugation Increased indirect bilirubin are toxic in newborns. The indirect form of bilirubin is hydrophobic, passes hemato-encefalic barrier and may lead to nuclear jaundice (kernicterus) Tratment: fototherapy with UV. In skin indirect bilirubin (insoluble) will be transformed in direct bilirubin (hydrosoluble) nontoxic, which is eliminated in urine. Phenobarbital administered preventive to mothers, with risk of early birth. The Phenobarbital passes the placenta and induces the synthesis of UDP glucuronil transferases Unsolved jaundice after 10 days, rises a pathological cause.

B. Pancreas exploration

Pancreas exploration
Assessment of pancreatic function:
1.

Serum enzymes:
1.

amylase (serum+urine). Total amylase represent the sum of pancreatic and salivary enzymes (may be increased in salivary pathology: infections with urlian virus parotidites, tumors, calculus) - may increase in neighborhood pathology (ulcer penetrant in pancreas, infarct intestinomezenteric, acute colecistitis, intestinal occlusion) - may increase in gynecological pathology (extrauterin pregnancy, ovarian tumour) 2. Trypsin 3. Lipase

2.

Functional tests: Exocrine:

1. 2. 3.

4.

Secretin test (measure bicarbonate output) Lundth test (measure pancreatic digestive capacity) PABA test (oral adm of bentiromide, followed by measurement of p-aminobenzoic acid in the urine or blood) Faecal fat

Endocrine:
1.

Glucose tolerance test

Acute pancreatitis
Acute Pancreatitis Amylase increases in the first 6 hours after onset and stays increased about 2 days; after that period amylase is increased in urine only Patients that develop acute Kidney Insufficiency, hyperamilasemia may stay longer increased Other parameters: glycemia, triglicerides, renal function (urea, creatinine), Calcium Associated with: alcoholism, biliary tract disease May be precipitated by: hyperchylomicronaemia Biochemical tests:
Serum amylase Urinary amylase Serum trypsin Serum lipase Secondary: hypocalcemia, hyperglycemia, hyperbilirubinemia

Chronic pancreatitis
Chronic Pancreatitis Clinical features:

Severe epigastric pain Weight loss steatorrhoea Alcoholism Calcification of pancreas Recurrent acute pancreatitis -increased or normal amylase values -microscopic examination of digestion faeces Functional exocrine tests: secretin, Lundth, PABA, OGTT

Aetiology:

Laboratory investigation:

Pancreatic cancer- cc de cap de pancreas colestasis Pancreatic lipase specific for pancreas microscopic examination of digestion - faeces

C. Gastrointestinal exploration

Gastrointestinal exploration
Gastric exploration

Basal and stimulated gastric acidity Infection with Helicobacter pylori urease test, Ag HP, Ab HP (IgG) Occult Blood Test- Gregersen test. Attention to diet, drugs, gingival hemorrhagies In case of digestive hemorrhagiescomplete hemogramm

Biliary ducts exploration

Biliary drieinage aspect

macroscopic Bila A - intestinal Bila B - vesicular Bila C hepatic Turbid, purulent aspect Microscopic examinationleucocytes, epithelial cells, cholesterol cristals, tumoral cells, lamblia (giardia) chysts Biliculture

Exploration of intestines

Occult Blood test Complete Hemogramm Microscopic examination of digestion muscular

fibres, lipid droplets, starch granules Coproparazitologic examination- parasites, eggs of parasites Coproculture Shigella, Salmonella, E.coli (enterotoxigen, enteropatogen, enterohemoragic)