LIVER FUNCTION TEST

Dr. P. Mohan Kumaresh

Institute of Biochemistry,
Madras Medical College,
Chennai
• Tests based on excretory function
BLOOD/SERUM URINE
Total Bilirubin Bile pigment
Direct Bilirubin Bile salt
Indirect Bilirubin Urobilinogen

• Tests based on enzyme levels

• Tests based on synthetic function
 TEST BASED
ON
EXCRETORY FUNCTIONS
 CATABOLISM OF HEME  BILIRUBIN
RETICULO- BLOOD LIVER INTESTINE ENTERO-
ENDOTHELIAL HEPATIC
SYSTEM CIRCULATION
RBC lysis Bilirubin Bilirubin – Albumin Bilirubin (Conjugated)
(unconjugated) complex
Bacterial
+ enzymes
Hemoglobin Albumin Albumin
Bilirubin
Globin (Unconjugated)
Heme Bilirubin
(Unconjugated)
Iron
UDP
Heme Bilirubin – Urobilinogen LIVER
Glucuronyl
oxygenase Albumin transferase
complex
Biliverdin
Bilirubin Stercobilinogen
(Conjugated)
Biliverdin
reductase KIDNEY

Bilirubin FAECES
(Unconjugated) BILE Urinary
Urobilinogen
CONJUGATION OF BILIRUBIN
Bilirubin (Unconjugated)
UDP-Glucuronic acid
UDP Glucuronyl
transferase

UDP
Bilirubin monoglucuronide (20%)
UDP-Glucuronic acid
UDP Glucuronyl
transferase

UDP
Bilirubin diglucuronide (80%)
Hemoglobin Other heme- proteins
6gms/day

250 mg Bilirubin 50 mg Bilirubin

300 mg Bilirubin/ day

UNCONJUGATED
BILIRUBIN
• Indirect bilirubin
• Insoluble in water
• Never excreted in urine even if
blood level is raised.
• van den Bergh reaction 
Indirect positive
CONJUGATED
BILIRUBIN
• Direct bilirubin
• Soluble in water
• Excreted in urine when blood
level is raised (not in normal)
• van den Bergh reaction 
Direct positive
 van den Bergh reaction
• Direct positive: Conjugated bilirubin
Conjugated bilirubin + Di-azotised suofalinic acid Purple colour

• Indirect positive: Unconjugated bilirubin

Unconjugated bilirubin + Di-azotised suofalinic acid No colour
+
Methanol

Purple colour

• Biphasic reaction: Both

Both + Di-azotised suofalinic acid Purple colour + Methanol

Purple colour intensifies

 BILE ACID & SALT METABOLISM
LIVER INTESTINE ENTERO HEPATIC
CIRCULATION
Bile salts (15-30 gms/day)
Cholesterol

7-α HYDROXYLASE
Emulsify fat LIVER
Cholic acid Cheno deoxy cholic acid

Taurine 98%
or Absorbed by intestinal
Glycine cells

Tauro-cholic acid Tauro-cheno- deoxy cholic acid

Glyco- cholic acid Glyco-cheno- deoxy cholic acid FAECES
0.5 gms/day bile salt is
excreted

Na+/ K+

Na+/ K+ salts of bile acids (BILE SALTS)

 Secondary bile acids
Primary bile acids
Cholic acid Cheno-deoxy-cholic acid
Intestine

Deoxy-cholic acid Litho-cholic acid

Secondary bile acids
 URINE TEST
Bilirubin Fouchet’s test:
Bilirubin + Ferric chloride Green colour

Gmelin’s test:
Bilirubin + HNO3 Green fluorescence

Bile salt Hay’s test:

Sulphur powder sinks to bottom

Urobilinogen Ehrlich’s aldehyde test:

Urobilinogen + Ehrlich’s aldehyde reagent
Red/pink colour
 NORMAL FINDINGS
BLOOD/SERUM URINE

Total Bilirubin 0.2 – 1.0 mg/dL Bilirubin Absent

Direct Bilirubin 0.1 – 0.4 mg/dL Bile salt Absent
Indirect Bilirubin 0.2 – 0.7 mg/dL Urobilinogen Present in
trace
amount
(< 4mg/day)
 JAUNDICE
Hyperbilirubinemia – Serum bilirubin above 1.0mg/dL
Icterus – yellow discolouration of skin, sclera
Serum bilirubin above 2 mg/dL

JAUNDICE

HEMOLYTIC OBSTRUCTIVE
Or HEPATIC Or
PRE-HEPATIC POST-HEPATIC
 HEMOLYTIC JAUNDICE
Causes: RBC – sickle cell anemia,
hereditary spherocytosis

G-6-PD deficiency

Incomptiable blood transfusion

Infection – malaria
Antibody mediated
 PATHOGENESIS IN HEMOLYTIC JAUNDICE
RETICULO- BLOOD LIVER INTESTINE ENTERO-
ENDOTHELIAL HEPATIC
SYSTEM CIRCULATION
RBC lysis - Increased Bilirubin Bilirubin – Albumin Bilirubin (Conjugated)
(unconjugated) complex
INREASED
Bacterial
Hemoglobin + Albumin enzymes
Albumin Bilirubin
Globin (Unconjugated)
Heme Bilirubin
(Unconjugated)
Iron
UDP Urobilinogen LIVER
Heme Bilirubin – Glucuronyl INCREASED
oxygenase Albumin transferase
complex
Biliverdin
Bilirubin
(Conjugated) Stercobilinogen
INCREASED INCREASED
Biliverdin KIDNEY
reductase

Bilirubin
(Unconjugated) - FAECES Urinary
INCREASED BILE DARK COLOURED Urobilinogen
INCREASED
 FINDINGS IN HEMOLYTIC JAUNDICE

BLOOD/SERUM URINE FAECES

Total Bilirubin Increased Bilirubin Absent DARK COLOURED

Direct Bilirubin Normal Bile salt Absent
Indirect Bilirubin Increased Urobilinogen
Increased

UNCONJUGATED
HYPERBILIRUBINEMIA
 OTHER CAUSES OF UNCONJUGATED
HYPERBILIRUBINEMIA

• Neonatal physiological jaundice

• Criggler Najjar Type I & II
• Gilbert’s syndrome
 OBSTRUCTIVE JAUNDICE
• Obstruction to biliary duct
• Stones cholelithiasis
• Cancer head of pancreas
• Cirrhosis
PATHOGENESIS OF OBSTRUCTIVE JAUNDICE
RETICULO- BLOOD LIVER INTESTINE ENTERO-
ENDOTHELIAL HEPATIC
SYSTEM CIRCULATION
RBC lysis Bilirubin Bilirubin – Albumin Bilirubin (Conjugated)
(unconjugated) complex
Bacterial
+ enzymes
Hemoglobin Albumin Albumin DECREASED
Bilirubin
Globin (Unconjugated)
Heme Bilirubin
(Unconjugated)
Iron
UDP
Heme Bilirubin – Urobilinogen LIVER
Glucuronyl
oxygenase Albumin transferase
complex
Biliverdin
Bilirubin Stercobilinogen
(Conjugated)
Biliverdin
reductase KIDNEY
Conjugated
bilirubin
regrugitates
Bilirubin FAECES light coloured DECREASED
into blood
(Unconjugated) stream – BILE Urinary
increased Urobilinogen
 BILE SALT IN OBSTRUCTIVE JAUNDICE
LIVER INTESTINE ENTERO HEPATIC
CIRCULATION
Bile salts (15-30 gms/day)
Cholesterol

7-α HYDROXYLASE
Emulsify fat LIVER
Cholic acid Cheno deoxy cholic acid

Taurine 98%
or Absorbed by intestinal
Glycine cells

Tauro-cholic acid Tauro-cheno- deoxy cholic acid

Glyco- cholic acid Glyco-cheno- deoxy cholic acid FAECES
BULKY, GREASY
STEATORRHEA
Na+/ K+

Na+/ K+ salts of bile acids (BILE SALTS)

Regrugitated into blood stream  excreted in urine
 FINDINGS IN OBSTRUCTIVE JAUNDICE

BLOOD/SERUM URINE FAECES

Total Bilirubin Increased Bilirubin Present PALE CLAY
Direct Bilirubin Increased Bile salt Present COLOURED STOOLS
Indirect Bilirubin Normal Urobilinogen Absent STEATORRHEA

HIGH COLOURED URINE

Conjugated hyperbilirubinemia
Pruritis – itching
Fat soluble vitamin deficiency
 OTHER CAUSES OF CONJUGATED
HYPERBILIRUBINEMIA
• Dubin-Johnson syndrome
• Rotor syndrome
 HEPATIC JAUNDICE
• LIVER DISEASE
– Hepatitis – Hep A, B, C, D, E
– Alcoholism
– Drugs
– Toxins
 PATHOPHYSIOLOGY
Destruction of hepatocytes

FINDINGS IN HEPATIC JAUNDICE

BLOOD/SERUM URINE FAECES

Total Bilirubin Increased Bilirubin Present Normal

Direct Bilirubin Increased Bile salt Absent
Indirect Bilirubin Increased Urobilinogen Decreased
or
Normal

Both conjugated & unconjugated bilirubin raised

 LIVER ENZYMES
• ALT – Alanine transaminase (SGPT)
• AST – Aspartate transaminase (SGOT)
• Alkaline phosphatase
• γ – Glutamyl transpeptidase
• ALT & AST
– Hepatocytic cytosolic enzymes
– Increased whenever there is damage to
hepatocytes – HEPATIC JAUNDICE
– AST is also increased in cardiac disease
– Normal levels: ALT = 15 – 45 IU/L
AST = 10 – 40 IU/L
• ALP:
– Present in biliary epithelium & osteoblast
– Elevated in obstructive liver disease & bone
disorders
– Normal values = 3 – 13 KA/dL
40 – 125 IU/L
• GGT:
– Present in liver, kidney, prostate
– Induced by alcohol
– Increased in alcoholic liver disease
– Normal values = 10 – 30 IU/L
 LIVER ENZYMES IN JAUNDICE
HEMOLYTIC HEPATIC OBSTRUCTIVE
Normal Increased Normal
ALT
Or Slightly increased
AST
Normal Normal Increased
ALP
Or Slightly
increased
Normal Increased in Normal
GGT alcoholism
 OTHER TEST
• Serum Albumin: Decreased
• Plasma Prothrombin time: Prolonged