You are on page 1of 47

PEMERIKSAAN LAB PADA

PENEGAKAN DIAGNOSA
KELAINAN HEPAR &
SISTEM BILIER
Dr. Rahma Triliana, S.Ked. M.Kes
Blok Gastroenterohepatologi II
Mei 2011

ANATOMY of LIVER

a) A liver lobule to show the direction of blood flow from the portal system
to the centrilobular veins and thence to the inferior vena cava
b) The blood flow through the sinusoids of the liver lobule and the passage
of bile from the bile canaliculi to the bile ducts

LIVER FUNCTION

Excretion

Synthesis & Storage

Produce substance related to glucose, protein, & fat metabolism


Plasma proteins, lipoproteins synthesis e.g. Albumin, globulin,
VLDL, & HDL
Produce coagulation factors (I XIII)
Storage of fat, glycogen, vitamins B12, A, K
Bile salts synthesis

Metabolism

Excrete waste product via urine or bile e.g. Amoniac


Bilirubin metabolism & detoxification

Biotransformation of various exogenous or endogenous substance


drugs (activation or deactivations)
Carbohydrate, lipid, protein metabolism

Portal vein clearance, tolerance


8

10

DIAGNOSING
HEPATIC & BILIARY
SYSTEM DISORDER

12

SYMPTHOMS of
HEPATOBILIARY DISEASE

Jaundice Dark Urine & Stool Characteristics changes


Fatigue
Pruritus >> in cholestasis
Poor Appetite & Weight Loss
Abdominal Pain
Alterations in the Senses of Taste & Smell complications
Personality Changes & Sleep Disturbances hepatic encephalopathy
Dyspnea
Bleeding
Vision Disturbances vitamin A Deficiency
Bone Pain and Fractures vitamin D Deficiency
Pain Peripheral neuropathy in liver disease secondary to cholestasis
Hyperpigmentation -melanocytestimulating hormone
Chills and Rigors infection
Sexual Dysfunction & Disinterest Hormonal changes, Psychological
Muscle Cramps

13

SIGN

Hepatomegaly
Fetor Hepaticus
Scleral icterus
Skin-yellow discoloration
Spider telangiectases
Skin hyperpigmentation &
hemochromatosis
Xanthomatosis, xanthelasmas
Purpura
Telangiectases
Excoriations & prurigo
nodularis
Parotid Glands enlargement
Testicular atrophy &
feminization, gynecomastia.

Breath sounds changes


Platypnea
Dilated veins on the
abdominal wall.
Venous hum, bruit, hepatic
friction rub
Distended abdomen with
bulging flanks
Shifting dullness, undulation
Abdominal tenderness
Splenomegaly
Red palms extremity
Acquired finger clubbing
Lower extremity edema
Alterations in personality

14

15

LABORATORY
EXAMINATION IN
HEPATIC &
BILIARY SYSTEMS
DISORDERS

BLOOD TEST

Liver Function Test Evaluate hepatocytes integrity


& liver cell function

Serial of test & drawn together


Help to identify:

Hepatocellular injury or Cholestatic problems


Time (Acute / Chronic disorder)
Severity

Identify some causes of cirrhosis or hepatic damage

Detect autoantibodies e.g. Antimitochondrial


antibodies in PBC
Genetic testing haemochromatosis
Circulating hepatitis viral marker

17

Liver Function

Excretion Detects jaundice & severity

Synthesis & metabolism Chronic & severity marker

Albumin, Prothrombin, Total Protein, 5-nucleotidase


Glucose, Cholesterol, TG, LDL, HDL level

Hepatic damage cellular integrity

Bilirubin (Total = Conjugated/direct + Unconjugated/indirect)


Amoniac
Asam empedu/bile acids

Alkaline phosfatase (ALP) Cholestatic problems


Gamma-glutamyl transferase (GGT) Cholestatic problems
Aspartate aminotransferase (AST/SGOT) liver damage
Alanine aminotransferase (ALT/SGPT) liver damage
Drug/toxin level e.g alcohol level, paracetamol etc
Marker of viral hepatitis

Cancer

Alpha fetoprotein

18

LIVER ENZYMES
Cellular Integrity

ALT( N < 40 IU) > spec AST for liveracute cond.


AST (N < 40 IU) Increase in

Rasio De Ritis = AST/ALT Normal < 1, if > 1 shows


chronic condition or non liver cellular injury
Toxic, drugs or viral hepatitis > 10-20X URL ALT > AST
Chronic Liver diseases, Cholestatic intra-ekstrahepatal &
chirrhosis N or 4-5x URL
Cancer (primary or metastasic) N to 5-10X URL
Alcohol related disease Slightly-Moderate (35X URL)
Myocardial Infraction/IMA in 1824 hours, N in Day-4
or -5 if (-)new lesion. 5-10x URL, if >10-15X= fatal IMA.
Muscle injury or damage 8X URL
Other organ injury (Lung, Pancreas, ETC) N--2-5X URL

19

AbNormal LFT
AST > 3x URL
ALP < 2X URL

AST < 3x URL


ALP > 2X URL

Penyakit Hepatoseluler

Penyakit Kolestatik

Albumin

Normal
Hepatitis
Akut

Menurun
Hepatitis
Kronis

Kolestasis
Akut

Kolestasis
Kronis

USG / Kolangiograf
Intrahepatik
Kolestasis

Ekstrahepati
kKolestasis

LIVER ENZYMES
Cholestatic Enzymes

GGT (N < 15 (F), < 20 (M) increase in

Cholestatic intra-ekstrahepatal 5-30X URL


Hepatitis 2-5X URL (Not spesifc)
Cancer (primary or metastasic) High
Fatty liver & drug intoxication 2-5X URL
Acute-Chronic Pankreatitis, Cancer of
pankreas with hepatobiliary obstruction 515X URL

ALP (N: 180 220) see flow chart


21

ALP Meningkat
5 nucleotidase / GGT
Normal

Meningkat

Dari tulang,
plasenta atau
usus
Dilatasi Bilier
Ekstrahepatik
kolestasis

Penyakit Hepatobilier
USG / CT Scan
Focal Mass
Kemungkinan:
Ca
Hepatoseluler
Limfoma
Metastase
Aspirasi Hati
Biopsi Hati

Dilatasi / Massa
(-)
AMA Test
(+)

Sirosis
()
Bilier
Primer
Kemungkinan:
Drug induce
TBC
Histoplasmosis

OTHER TESTS

Plain X-Ray See AbN abdomen structure


Abdomen USG detect liver & gall bladder size, texture, mass &
portosystemic vascular shunts
CT-Scan & MRI = USG, >> sensitive
Biliary endoscopy
Endoscopic Retrograde Cholangiopancreatography/ERCP
investigate & treat obstructive jaundice.
Liver & Biliary System Biopsy See histologic structure Indentify
Fibrosis, Regenerative hepatocyte nodules, & causes of cirrhosis using
special histochemical and immunohistochemical to confirm diagnosis

23

COMMON
DISORDERS

25

Liver Disorders

Wide range of symptoms & signs Most common:

Asymptomatic
Malaise, fatigue, Loss of appetite, Nausea
Jaundice
Pain in the right upper quadrant

Common disorders:

Viral Hepatitis
Toxic hepatitis >> alcohol, drugs, herbs & toxics substance
Liver abscesses by amoebae, bacteria or parasites.
Liver damage Liver failure defects in drugs, nutrition,
metabolism & coagulation systems
Chronic damage Liver fibrosis Cirrhosis.
Cancer (metastatic >> primary liver cancers)
Portal hypertension Esophageal bleeding, Asites
Hepatic Coma.
26

SPESIFIC HEPATITIS
CAUSES
MARKER
MARKER

Hepatitis A

IgM anti HAV, HAV DNA

Hepatitis B

HBsAg, Anti-HBs, HBeAg, Anti HBe, HBV


DNA, Anti-HBc,

Hepatitis C

Anti-HCV (IgM & IgG), HCV RNA, HCVag

Hepatitis D

HBsAg, IgM anti HDV, HDVAg

Autoimmune

ANA, ASTMA, SLA, Anti LKM

Toxic Hepatitis Drugs, Toxin level, ALT/AST


Idiopathic

Biopsy

ASTMA: Anti smooth muscle antibody, LKM: Anti-liver-kidney microsomal antibody, SLA:
Soluble liver antigen

+++

+++
+++
++

+++

+++
+
++

+++
-

28
Harissons: Principles of Internal Medicine

Inkubasi

Fase Akut

Fase
Konvalesen

Sembuh

4-12 minggu

2-12 minggu

2-16 bulan

Tahun

Total Anti-HBc
Anti HBe

HBsAg

Anti HBs

IgM Anti-HBc
HBeAg

Kontak

HBV DNA

Window period

HBV- DNA , HBe Ag, HBs Ag muncul hampir bersamaan.


HBc Ag tidak terdapat diserum.

Imunitas
29

INTERPRETATION of HEPATITIS B
MARKER

30

31

Sumber : Isa K. Musahwar

Inkubasi

Fase Akut

Penyembuhan

4-7 minggu

4-12 minggu

Tahun
Anti HCV

HCV RNA

HCV Ag

Kontak
32

Drugs That Cause Liver


Damage
Analgesics

Cardiac drugs

Methyldopa
Amiodarone

Psychotropic drugs

Paracetamol
Aspirin
Nonsteroidal antiinflammatory drugs

Monoamine oxidase inhibitors


Phenothiazines (such as chlorpromazine)

Others

Sodium valproate
Oestrogens (oral contraceptives & hormone replacement
therapy)

33

34

35

36

37

38

Biliary Disorders

Sign & Sympthoms

Jaundice Classic Sympthoms


Pale stool & dark urine
Itching pruritogenic substances in bile
Defects in fat absorption Steatorrhoea, weight loss &
nutritional deficiency.
Pain, fever & malaise

Disorder of Biliary Sistems

Intrahepatic cholestasis No blockage in biliary system

Autoimmune Intrahepatic Damage of Bile Ducts = Primary


biliary cirrhosis (PBC)
Due to liver disorders

Extrahepatic cholestasis Blockage in biliary system +

Gallstones
Cholecystitis, Cholangitis
Pancreatitis

39

40

Lab Test In Jaundice


Bilirubin Level (Total, direct & indirect) : N = < 1,00/ 0,25 / 0,75
Jaundice (+) bilirubin 2 x Normal Limit or > 2,0-2,5 mg/dl)

Prehepatik Hepatic
Jaundice
Jaundice

Posthepatic
Jaundice

Unconjugated
Bilirubin (Indirect Bil)

Conjugated Bilirubin

Bilirubin in urine

Trace

2+ - 4+

> 3+

Urobilin in urine

++

+/-

+/-

Brown

Light
Brown

pale

(Direct Bil)

Feces colour

41

CAUSES PORTAL
IncreasedHYPERTENSION
resistance to flow

Prehepatic (portal vein obstruction)

Hepatic

Cirrhosis
Acute alcoholic liver disease
Congenital hepatic fibrosis
Idiopathic portal hypertension (hepatoportal sclerosis)
Schistosomiasis

Posthepatic

Congenital atresia or stenosis


Thrombosis of portal vein or splenic vein
Extrinsic compression (for example, tumours)

BuddChiari syndrome
Constrictive pericarditis

Increased portal blood flow

Arterialportal venous fistula


Increased splenic flow

42

44

45

46

47

You might also like