9/27/13

OUTLINE OF DISCUSSION

§ Anatomy and Physiology

§ Biochemical functions
§ Diseases
§ Laboratory tests

3 4

Microscopic Anatomy 3 Systems of the Liver

§ Hepatocyte system
-  Metabolic reactions and
macromolecular synthesis
§ Biliary system
-  Metabolism of bilirubin and bile
salts
§ Reticuloendothelial system
-  Immune system and production
of heme and globin metabolites

5 6

1
 9/27/13

4 Major Functions
of the Liver
§ Synthesis
§ Detoxification
§ Storage
§ Excretory/secretory

7 8

Synthetic Activity Detoxification and Drug Metabolism

§ Proteins § “First Pass”
§ Carbohydrates § 2 ways:
- Glucose to glycogen - Bind and inactivate the toxin
- AA, pyruvate, & lactate to glucose - Chemically modify and excrete the toxin
§ Lipids
§ Vitamins: fat soluble and some water soluble

9 10

Storage
§ Glycogen
§ Lipids
§ Amino acids and Proteins

11 12

2
 CHAPTER 24 ■ LIVER FUNCTION 517

9/27/13
Diaphragm
Falciform ligament

Left lobe of liver

Right lobe of liver
Stomach
Gallbladder

FIGURE 24-1. Gross anatomy of the liver.

hepatic ducts merge to form the common hepatic duct, vein) with portal triads at each of the corners. Each por-
which is eventually joined with the cystic duct of the tal triad contains a hepatic artery, a portal vein, and a

Pathway of Bile
gallbladder to form the common bile duct. Combined di- bile duct surrounded by connective tissue. The liver con-

Excretory and Secretory Function

gestive secretions are then expelled into the duodenum tains two major cell types: hepatocytes and kupffer cells.
(Fig. 24-3). The hepatocytes, making up approximately 80% of the
volume of the organ, are large cells that radiate outward
from the central vein in plates to the periphery of the lob-
Microscopic Anatomy
ule. These cells perform the major functions associated
The liver is divided into microscopic units called lobules. with the liver and are responsible for the regenerative
The lobules are the functional units of the liver; they are properties of the liver. Kupffer cells are macrophages that
§ Bile responsible for all metabolic and excretory functions
performed by the liver. Each lobule is roughly a six-sided
line the sinusoids of the liver and act as active phagocytes
capable of engulfing bacteria, debris, toxins, and other
Terminal ileum
-  Comprises structure
of bile acids or salts; bile pigments (primarily
with a centrally located vein (called the central substances flowing through the sinusoids (Fig. 24-4). Cholesterol Excretion and colon with
bacteria
bilirubin esters), cholesterol, and other substances extracted
Right Left
from blood Cystic duct hepatic duct hepatic duct

-  Production rate = 3L/day

Dehydration to
-  Excretion rate = 1L/day Liver Bile Salts
Common
hepatic duct
2° bile acids

§ Bilirubin Common
bile duct Absorbed into
-  Principal pigment in bile
Gallbladder Anatomy 1°Bile acids conjugation portal
FIGURE 24-2. Blood supply to liver. FIGURE 24-3. Excretory system of the liver.
circulation

13 14

Bilirubin Pathway of Bilirubin Production

RBC Hemoglobin
§ Principal pigment in bile
§ Derived from iron-containing heme
- RBC’s Heme Globin

- Proteins (myoglobin, cytochromes, and

catalase) Iron Porphyrin

Liver Circulation

15 16

Porphyrin Disorders of the Liver

Biliverdin
§ Drug and Alcohol-Related Disorders
§ Reye’s Syndrome
§ Tumors
§ Hepatitis
§ Cirrhosis
§ Jaundice

20%
80%

17 18

3
 9/27/13

Drug and Alcohol-Related Disorders Drug and Alcohol-Related Disorders

§ Drugs § Ethanol
-  Anti-psychotics - Small amounts: mild, unapparent injury
-  Antibiotics
- Heavy consumption: alcoholic cirrhosis
-  Anti-neoplastic agents
-  Anti-inflammatory drugs
- >1000 mg/L = under the influence of alcohol
-  Elevated liver function tests - 3000 mg/L = CNS impairment/coma
-  Hepatic failure or cirrhosis - 4000 mg/L = death

19 20

Reye’s Syndrome Tumors

§ Idiopathic § Hepatocellular carcinoma/hepatocarcinoma/
§ Arising primarily in children (few cases in adults) hepatoma
§ Usually occurs following recovery from viral infection § Hepatocellular adenoma and hemangiomas
§ Related to aspirin therapy § Primary or metastatic
- Neurologic abnormalities, elevated liver function
tests except bilirubin
§ Previous infection with hepatitis
- Death

21 22

530
Hepatitis PART 3 ■ ASSESSMENT OF ORGAN SYSTEM FUNCTIONS

§  Inflammation of the liver TABLE 24-3 THE HEPATITIS VIRUSES

SEROLOGIC
§  A: picorna virus; fecal-oral route INCUBATION PRIMARY MODE CHRONIC DIAGNOSIS
NUCLEOTIDE PERIOD OF TRANSMISSION VACCINE INFECTION AVAILABLE
§  B: hepadna virus
Hepatitis A RNA 2–6 weeks Fecal-oral Yes No Yes
§  C: flavivirus
Hepatitis B DNA 8–26 weeks Parenteral, sexual Yes Yes Yes
§  D: delta agent (needs HBsAg)
Hepatitis C RNA 2–15 weeks Parenteral, sexual No Yes Yes
§  E: Hepevirus; fecal-oral route Hepatitis D RNA — Parenteral, sexual Yes Yes Yes
§  F: Toga virus Hepatitis E RNA 3–6 weeks Fecal-oral No ? Yes
§  G: G-B virus
§  Transfusion-transmitted virus
§  SEN virus symptoms, including jaundice, dark urine, fatigue, nausea, The presence of elevated titers of IgG anti-HAV in the ab-
vomiting, and abdominal pain. Some subtypes, such as sence of IgM indicates a past infection. Another reliable
hepatitis virus B and C, can lead to the prolonged eleva- method to detect acute infection in patients is assaying
§  Alcoholic hepatitis tion of serum transaminase level (longer than 6 months), for the presence of viral antigen, which is shed in the
§  Drug-induced a condition termed chronic hepatitis. Routes of transmis- feces. However, the antigen is no longer present soon
sion vary from one viral subtype to another. Hepatitis A after liver enzymes have reached their peak levels.
and E are typically caused by ingestion of contaminated Another method for detecting HAV infection is amplifi-
food or water. Hepatitis B, C, and D usually occur as a re- cation of viral RNA by reverse transcription–polymerase
sult of parenteral contact with infected body fluids (e.g., chain reaction (RT-PCR). Nucleic acid detection tech-
23 from blood transfusions or invasive medical procedures niques are more sensitive than immunoassays for viral
using contaminated equipment) and sexual contact. Refer antigen to detect HAV in samples of different origins
to Table 24-3 for a list of the hepatitis viruses. (e.g., clinical specimens, environmental samples, or
food). Because of the high proportion of asymptomatic
Hepatitis A HAV infections, nucleic acid amplification techniques
Hepatitis A (HAV), also known as infectious hepatitis or are useful to determine the extent to which unidentified
short-incubation hepatitis, is the most common form of infection occurs.57
viral hepatitis worldwide. It is caused by a nonenveloped The availability of vaccines to provide long-term
RNA virus of the Picornavirus family. Tens of millions of immunity against HAV infection has the potential to
HAV infections occur annually, with the most common significantly reduce the incidence of disease and possi-
reported source of infection in the household occurring bly eliminate the transmission of this virus world-
via contaminated or improperly handled food.51 Because
wide.58–61 In 2006, following the approval of the HAV
HAV is excreted in bile and shed in the feces, which can
contain up to 109 infectious virions per gram, the fecal-
for children in the United States, the U.S. Food and
Drug Administration/Centers for Disease Control and
4
oral route is the primary means of HAV transmis-
Prevention (FDA/CDC) recommended that all children
sion.52,53 Patients with HAV infection present with receive the HAV vaccine as early as age 12–23 months.62
symptoms of fever, malaise, anorexia, nausea, abdominal
The use of this vaccine has significantly reduced the in-
discomfort, dark urine, and jaundice. Symptoms are gen- cidence of hepatitis A in the United States and has there-
erally self-limited and resolve within 3 weeks. However,
fore changed the epidemiology of this infection.
in rare instances, patients develop fulminant liver failure.
Chronic infection with HAV is not found and there is Hepatitis B
 9/27/13

Cirrhosis
§ Greek word: yellow
§ Irreversible scarring of the liver
§ 2 cardinal features: fibrosis and nodules

25 26

Cirrhosis
§ May lead to portal hypertension
-  Splenomegaly (slight)
-  Esophageal varices
-  Fatal hemorrhage
§ Synthetic function is affected: hypoalbuminemia, low clotting
factors (hemorrhage)
§ Ascitic fluid accumulates in the abdomen

27 28

Jaundice or Icterus Classification of Jaundice

§ French word: “jaune” § Pre-hepatic Jaundice/ Hemolytic Hyperbilirubinemia
§ Yellowish discoloration of the skin and sclerae § Hepatic Jaundice/ Hepatocellular Hyperbilirubinemia
§ Hyperbilirubinemia: >1 mg/dL up to 2-3 mg/dL § Post-hepatic Jaundice/ Obstructive Hyperbilirubinemia
§ Associated with KERNICTERUS

29 30

5
 9/27/13

Pre-hepatic Jaundice/ Hemolytic

Hyperbilirubinemia
§ Too much RBC destruction
§ Excessive amount of bilirubin is presented to the liver for
metabolism
§ Characterized by unconjugated hyperbilirubinemia
§ Malaria and Hemolytic Anemia

-  B1 is water insoluble and bound to albumin.

31 32

Hepatic Jaundice/ Hepatocellular Gilbert Syndrome

Hyperbilirubinemia
§ Due to impaired cellular uptake, defective conjugation, or § Gilbert-Muelengracht syndrome
abnormal secretion of bilirubin by the liver cell § Impaired cellular uptake of bilirubin
§ Asymptomatic; only mild icterus
§ Increased B1 and B2
§ Increased B1
§ Viral hepatitis, liver cirrhosis (Laennec’s cirrhosis –alchohol),
due to Fasciola hepatica

33 34

Crigler-Najjar Syndrome Dubin-Johnson Syndrome

and Rotor’s Syndrome
§  Deficiency of the enzyme uridyl diphosphate glucuronyl transferase
(UDPGT) §  DJ: Deficiency of the canalicular multidrug
resistance/multispecific organic anionic
transporter protein (MDR2/cMOAT)
§  Type I: complete absence of UDPGT
§  RS: idiopathic
-  No B2 is formed
§  Conjugated hyperbilirubinemia due to
-  Bile is colorless
defective excretion
§  Type II: relative deficiency of UDPGT (Arias Syndrome) Characteristics Dubin Johnson Rotor’s
-  Some B2 is formed Appearance of With black Normal histology
liver pigmentation
Lucey Driscoll: increased B1 (defect in UDPGT); congenital, Gallbladder No visualization Visualized by oral
visualization cholecystogram
maternal steroids
Total urine Normal w/ >80% High with <70% of
coproporphyrin of isomer 1 isomer 1

35 36

6
 522 PART 3 ■ ASSESSMENT OF ORGAN SYSTEM FUNCTIONS 9/27/13
jugated fraction. This syndrome is a relatively mild in na- unconjugated bilirubin (approximately 20 mg/dL) can
ture with an excellent prognosis. People with Dubin- be detected and treated.13
Johnson have a normal life expectancy, so no treatment Posthepatic jaundice is results from biliary obstructive
is necessary.10,11 disease, usually from physical obstructions (gallstones or
Rotor syndrome is clinically similar to Dubin-Johnson tumors), that prevent the flow of conjugated bilirubin
syndrome but the defect causing Rotor syndrome is not into the bile canaliculi. Since the liver cell itself is func-
known.12 It is hypothesized to be due to a reduction in tioning, bilirubin is effectively conjugated; however, it is
21 EVALUATION OF LIVER FUNCTION

Spleen
the concentration or activity of intracellular binding pro- unable to be properly excreted from the liver. Since bile
SER teins such as ligandin. Unlike in Dubin-Johnson syn- Post-hepatic Jaundice/ Obstructive
is not being brought to the intestines, stool loses its
drome, a liver biopsy does not show dark pigmented source of normal pigmentation and becomes clay-col-
Transporter protein
A B Ligandin (L) Secretory protein granules. Rotor syndrome is seen Hyperbilirubinemia
less commonly than ored. The laboratory findings for bilirubin and its
Dubin-Johnson syndrome; it is a relatively benign condi- metabolites in the above-mentioned types of jaundice are
Bilirubin (Bili) 1 Bili-L Bili + UDP-Gu § Impaired excretion of bilirubin caused by mechanical
tion and carries an excellent prognosis, and therefore summarized in Table 24-1. Mechanisms of hyperbiliru-
2 GT C treatment is not obstruction
warranted. However,of thean flow of bile
accurate diag- intobinemia
the intestines
may be found in Figure 24-6.
21 EVALUATION OF LIVER FUNCTION

Globin + Spleen heme

SER
Bili-Gu Bili-Gu nosis is required § Increased B2: stool
to aid in distinguishing loses
it from moreits
se-source of normal pigmentation =
Transporter protein
GT D 3 E rious liver diseasesCLAY that require
coloredtreatment.
A B Ligandin (L) Secretory protein Cirrhosis
Bilirubin (Bili) 1 Bili-L Bili + UDP-Gu Bili-(Gu)2 Bili-(Gu)2 Physiologic jaundice of the newborn is a result of a
Globin + heme
2 GT C deficiency in the enzyme glucuronyl transferase, one of Cirrhosis is a clinical condition in which scar tissue re-
Bili-Gu Bili-Gu
Sinusoid the last liver functions to be activated in prenatal life places normal,
GT D 3 E § Gallstones (cholecystolithiasis), stones in thehealthy
common liver tissue.
bile As the scar tissue re-
Bili-(Gu) Bili-(Gu) since bilirubin processing is handled by the mother of places the normal liver tissue, it blocks the flow of blood
duct (choledocholithiasis), constriction of bile ducts/strictures,
2 2

Hb Sinusoid the fetus. In premature births, infants may be born with- through the organ and prevents the liver from function-
Hb out glucuronyl transferase, parasitism the enzyme responsible for ing properly. Cirrhosis rarely causes signs and symp-
Hepatocyte
Hepatocyte bilirubin conjugation. This deficiency results in the toms in its early stages, but as liver function deterio-
RBC RBC Canaliculus Canaliculus
rapid buildup of unconjugated bilirubin, which can be rates, the signs and symptoms appear, including fatigue,
life threatening. When this type of bilirubin builds up in
Figure 21-2 Schematic summary of the pathway of bilirubin (Bili, in brown circles) transport and metabolism. Bilirubin is produced from metabolism of heme, primarily
in the spleen, and is transported to the liver bound to albumin. It enters the hepatocyte by binding to a transporter protein (red crescents) and crosses the cell membrane
nausea, unintended weight loss, jaundice, bleeding from
Figure 21-2 Schematic summary of the pathway of bilirubin (Bili, in brown circles) transport and metabolism. Bilirubin is produced from metabolism of heme, primarily
in the spleen, and is transported to the liver bound to albumin. It enters the hepatocyte by binding to a transporter protein (red crescents) andthe neonate, it cannot be processed and it is deposited the gastrointestinal tract, intense itching, and swelling
(circled 1), thus entering the cell. It binds to Y and Z proteins (not shown) and then to ligandin for transport to the smooth endoplasmic reticulum (SER). In the SER, bilirubin
crosses the cell membrane
is conjugated to glucuronic acid by UDP-glucuronyl transferase 1 (circled 2 and labeled GT), producing monoglucuronides and diglucuronides of bilirubin—Bili-Gu and Bili-
(Gu)2. Conjugated bilirubin is then secreted into the canaliculi (circled 3) by the adenosine triphosphate-binding cassette transporter protein MRP2/cMOAT/ABCC2 (shown
(circled 1), thus entering the cell. It binds to Y and Z proteins (not shown) and then to ligandin for transport to the smooth endoplasmic reticulum in the nuclei of brain and nerve cells, causing ker-
(SER). In the SER, bilirubin
as blue crescents). In overproduction disease (A), such as hemolytic anemia, unconjugated bilirubin is produced at rates that exceed the ability of the liver to clear it, leading
to a usually transient increase in unconjugated bilirubin in serum. In both Gilbert’s and Crigler-Najjar syndromes, mutations in the gene encoding UDP glucuronyl transferase in the legs and abdomen. Although some patients with
is conjugated to glucuronic acid by UDP-glucuronyl transferase 1 (circled 2 and labeled GT), producing monoglucuronides and diglucuronides of bilirubin—Bili-Gu and Bili-
(UDPGT1A1), shown at C in the figure, result in buildup of unconjugated bilirubin in hepatocytes and ultimately in serum. In Gilbert’s syndrome, there may also be a defect

2
nicterus. Kernicterus (shown often results in cell damage and
in the bilirubin transporter protein, shown at B in the figure. Mutations in the MRP2/cMOAT/ABCC2 gene result in defective secretory proteins, causing buildup of conjugated
(Gu) . Conjugated bilirubin is then secreted into the canaliculi (circled 3) by the adenosine triphosphate-binding cassette transporter protein MRP2/cMOAT/ABCC2
bilirubin in hepatocytes and, ultimately, in serum, resulting in the Dubin-Johnson syndrome (D), an autosomal recessive disease. Conjugated hyperbilirubinemia is also
cirrhosis may have prolonged
38 survival, they generally
as blue crescents). In overproduction disease (A), such as hemolytic anemia, unconjugated bilirubin is produced at rates that exceed the ability ofdeath the liver
intothe
clearnewborn,
it, leading and this condition will continue
found in the Rotor syndrome, possibly virus induced. In adults, blockade of any of the major bile ducts, especially the common bile duct, by stones or space-occupying
lesions such as tumors (E), is the most common cause of conjugated hyperbilirubinemia. have a poor prognosis. Cirrhosis was the twelfth leading
to a usually transient increase in unconjugated bilirubin in serum. In both Gilbert’s and Crigler-Najjar syndromes, mutations in the gene encoding UDP glucuronyl transferase
Hb, Hemoglobin; RBC, red blood cell.
(UDPGT1A1), shown at C in the figure, result in buildup of unconjugated bilirubin in hepatocytes and ultimately in serum. In Gilbert’s syndrome,until glucuronyl
there may transferase
also be a defect is produced. Infants with cause of death by disease in 2004, killing just over
males with this defect were found to have hyperbilirubinemia, but no within the ABC region and contain transmembrane domains involved in
in the bilirubin transporter protein, shown at B indeficit
the figure. Mutations in the MRP2/cMOAT/ABCC2
recognition of gene result in defective secretory proteins,
and out causing buildup of conjugated
females with
bilirubin in hepatocytes and,rubin
ultimately,
this enzyme
in serum,
levels (Bosma,
were found
resulting
1995). In some patientsin
to have elevated
the
with Dubin-Johnson
Gilbert’s
serum bili-
syndrome, the syndrome
cell membranes
substrates,
(D), andan include
which
autosomal
are transported
proteinsrecessive
across, into,
involved indisease. Conjugated
multiple drug
of
resistance
this type of jaundice
hyperbilirubinemia is alsoare usually treated with ultraviolet 27,000 people.14 In the United States, the most common
found in the Rotor syndrome, ratepossibly
of organic virus
anion uptake
induced.has been
In found to blockade
adults, correlate negatively
of
serum bilirubin (Persico, 1999), suggesting that an additional defect may
any with
of theto chemotherapeutic agents in cancer treatment. Some protein members
major bile ducts, especially the common bile duct,
utilize ABCs to regulate ion channels. Several genetic diseases result from
by radiation
stones or to destroy
space-occupying the bilirubin as it passes through cause of cirrhosis is chronic alcoholism and chronic
lesions such as tumors (E), isbethe
presentmost common
to cause cause of that
hyperbilirubinemia conjugated hyperbilirubinemia.
may be related to a transport transporter mutations, including the Dubin-Johnson syndrome, cystic
Hb, Hemoglobin; RBC, red blood deficit cell.
in the sinusoidal membrane of the hepatocyte. In this condition, fibrosis, age-related macular degeneration, Tangier disease, and progres- the capillaries of the skin. In extreme cases, some in- hepatitis C virus infection. Other causes of cirrhosis in-
total bilirubin, virtually all of which is unconjugated, is typically elevated sive familial intrahepatic cholestasis (Gottesman, 2001).
to 2–3 mg/dL; levels can increase further with fasting but seldom exceed Dubin-Johnson syndrome is associated with increased plasma conju- fants require an exchange transfusion. Because this con- clude chronic hepatitis B and D virus infection, autoim-
5 mg/dL. Because passive diffusion of bilirubin into hepatocytes occurs, gated bilirubin, typically with mild jaundice (total bilirubin, 2–5 mg/dL),
males with this defect were foundis rarely
this condition to have hyperbilirubinemia,
serious and may result in mild elevationsbut no
of bilirubin within
and intense the ABC region
dark pigmentation of the and contain
liver due transmembrane
to accumulation of lipofus- ditiondomains
is soinvolved
serious,in bilirubin levels are carefully and mune hepatitis, inherited disorders (e.g., !1-antitrypsin
such as those seen in hemolytic anemia as described previously. cin pigment. Thus conjugated bilirubin accumulates within the hepatocyte
females with this enzyme deficit Gilbert’swere found to have
been elevated serum bili- recognition of substrates, which whereare transported
it is detected in across, into, and out of
rubin levels (Bosma, 1995).
syndrome has perhaps overdiagnosed;
In some patients with Gilbert’s syndrome, the
it is most
quently diagnosed in young adults ranging in age from 20–30 years.
fre- and eventually back-diffuses
cell This
serum. membranes
inborn error and
into the circulation,
include
can sometimes be proteins
confused withinvolved frequently monitored
in multiple drug resistance
the Rotor syn- so the dangerously high levels of deficiency, Wilson disease, hemachromatosis, and galac-
However, normal bilirubin ranges are age dependent and actually reach drome, possibly of viral origin, where there is also a block in the excretion
rate of organic anion uptake has been
their highest levels infound to and
adolescents correlate negatively
young adults withas
(Rosenthal, 1984), to chemotherapeutic agents in cancer treatment. Some protein members
of conjugated bilirubin but without liver pigmentation (Berk, 1994d). In
discussed further later. these cases, liver biopsy often will reveal cytosolic inclusion bodies within
serum bilirubin (Persico, 1999), suggesting
In the more that
serious or type anof additional
I form the Crigler-Najjardefect
syndrome may(i.e., utilize ABCs to regulate ion channels. Several genetic diseases result from
hepatocytes.
be present to cause hyperbilirubinemia that may be related to a transport
homozygously nonfunctioning proteins), the unconjugated hyperbilirubi-
nemia becomes marked, almost always exceeding 5 mg/dL and causing
transporter mutations, including the Dubin-Johnson syndrome,TABLE
Biliary Obstruction. In adults, cholelithiasis is the most common cause
of hyperbilirubinemia. This condition results from the presence of bile
cystic 24-1 CHANGES IN CONCENTRATION OF BILIRUBIN IN THOSE
deficit in the sinusoidal membrane of the exceeding
jaundice, and sometimes hepatocyte.20 mg/dL. InAffected
this condition,
infants develop fibrosis, age-related macular degeneration, Tangier disease, and progres-
stones (that are composed of bilirubin or cholesterol) most commonly in
severe unconjugated hyperbilirubinemia, which typically leads to kernic-
total bilirubin, virtually all of deposition
terus, which is unconjugated,
of bilirubin in the brain, is typically
particularly elevated
affecting the basal
the common bile duct (choledocholithiasis). Most frequently, patients pre-
sive familial intrahepatic cholestasis (Gottesman, 2001).
senting with this condition are parous white females in early middle age
WITH JAUNDICE
to 2–3 mg/dL; levels can ganglia,
increase further
In the lesswith
severe fasting but seldom
activityexceed
mainly the lenticular nucleus, causing severe motor dysfunction
Dubin-Johnson syndrome is associated with increased plasma conju-
(giving rise to the semi-mnemonic, “fair, fecund, fortyish female”). Biliary

5 mg/dL. Because passiveThe

and retardation.
diffusion
mately of bilirubin
10% of normal,
type II form,
and survival into
enzyme
hepatocytes
to adulthood
is approxi-
occurs,
is possible (Berk, 1994c).
obstruction due to cholelithiasis results in elevation of total bilirubin, with
gated bilirubin, typically with mild jaundice (total bilirubin, 2–5 mg/dL),
>90% being direct bilirubin. In more than 90% of such patients, a con- SERUM
danger of kernicterus is a certainty at levels exceeding 20 mg/dL. It comitant rise in alkaline phosphatase occurs. The levels of this enzyme are
this condition is rarely serious
is vitaland may
to treat result
these infantsin mild
with elevations
phototherapy, of bilirubin
as discussed earlier, to and intense dark pigmentation of the liver due to accumulation of lipofus-
variable but are frequently above 300 international units (IU)/L. TOTAL CONJUGATED UNCONJUGATED
cause excretion of the unconjugated bilirubin. Inflammatory conditions of the biliary tract, such as ascending cholan-
such as those seen in hemolytic anemia as described previously. cin pigment. Thus conjugated bilirubin accumulates within the hepatocyte
TYPE OF JAUNDICE
gitis, also give rise to elevated serum levels of direct bilirubin and alkaline
BILIRUBIN BILIRUBIN BILIRUBIN
Gilbert’s syndrome has perhaps
Causes been
of Elevated Serumoverdiagnosed;
Levels of Conjugated it isBilirubin
most fre-
Excretion Deficits: Dubin-Johnson Syndrome. In another inborn error
and eventually back-diffuses into the circulation, where it is detected in
phosphatase, as discussed later in this chapter. The rise in direct bilirubin
often exceeds 5 mg/dL. In gram-negative sepsis, there can be what appears
quently diagnosed in young adultscalled
of metabolism, ranging in age syndrome,
the Dubin-Johnson from 20–30 there is ayears.
blockade
of the excretion of bilirubin into the canaliculi, caused by defects in the
serum. This inborn error can sometimes be confused with the Rotor
to be a mild inflammation of the biliary tract, resulting in mild elevation
of direct bilirubin to levels of 2–3 mg/dL. A concomitant elevation of
syn-
Prehepatic ↑ ↔ ↑
However, normal bilirubin ranges
adenosine are age
triphosphate dependent
(ATP)-binding and(ABC)
cassette actually reach
canalicular multi- drome, possibly of viral origin, where there is also a block in the excretion
alkaline phosphatase to levels of 200–300 IU/L is also observed.
their highest levels in adolescents
specific and young adults (Rosenthal, 1984),
organic anion transporter, MRP2/cMOAT/ABCC2 as
(Paulusma, of conjugated bilirubin but without liver pigmentation (Berk, 1994d). Hepatic
In hepatitis, in which toxic destruction of hepatocytes is due to viral, In
1997; Tsujii, 1999; Gottesman, 2001). This protein is a member of a family chemical, or traumatic causes, focal necrosis and/or cellular injury results
discussed further later. of approximately 100 different transporter proteins that share homology • Gilbert disease
these cases, liver biopsy often will reveal cytosolic inclusion bodies within
both in blocking conjugation of bilirubin and in excretion of conjugated ↑ ↔ ↑
In the more serious or298type I form of the Crigler-Najjar syndrome (i.e., hepatocytes. • Crigler-Najjar syndrome ↑ ↓ ↑
homozygously nonfunctioning proteins), the unconjugated hyperbilirubi- Biliary Obstruction. In adults, cholelithiasis is the most common cause
• Dubin-Johnson ↑ ↑ ↔
nemia becomes marked, almost always exceeding 5 mg/dL and causing of hyperbilirubinemia. This condition results from the presence of bile
jaundice, and sometimes exceeding 20 mg/dL. Affected infants develop stones (that are composed of bilirubin or cholesterol) most commonly • Rotor
in syndrome ↑ ↑ ↔
severe unconjugated hyperbilirubinemia, which typically leads to kernic- the common bile duct (choledocholithiasis). Most frequently, patients •pre- Jaundice of newborn ↑ ↔ ↑
terus, deposition of bilirubin in the brain, particularly affecting the basal senting with this condition are parous white females in early middle age
ganglia, mainly the lenticular nucleus, causing severe motor dysfunction
Posthepatic
(giving rise to the semi-mnemonic, “fair, fecund, fortyish female”). Biliary
↑ ↑ ↑
and retardation. In the less severe type II form, enzyme activity is approxi- obstruction due to cholelithiasis results in elevation of total bilirubin, with
Adapted with permission from Table 27-3 of Kaplan LA, Pesce AJ, Kazmierczak S. Clinical chemistry: theory,
mately 10% of normal, and survival to adulthood is possible (Berk, 1994c). >90% being direct bilirubin. In more than 90% of such patients, analysis, a con- correlation. 4th ed. St. Louis, Mo.: Mosby, 2003.
The danger of kernicterus is a certainty at levels exceeding 20 mg/dL. It comitant rise in alkaline phosphatase occurs. The levels of this enzyme are
is vital to treat these infants with phototherapy, as discussed earlier, to variable but are frequently above 300 international units (IU)/L.
cause excretion of the unconjugated bilirubin. Inflammatory conditions of the biliary tract, such as ascending cholan-
gitis, also give rise to elevated serum levels of direct bilirubin and alkaline
Causes of Elevated Serum Levels of Conjugated Bilirubin phosphatase, as discussed later in this chapter. The rise in direct bilirubin
Excretion Deficits: Dubin-Johnson Syndrome. In another inborn error often exceeds 5 mg/dL. In gram-negative sepsis, there can be what appears
of metabolism, called the Dubin-Johnson syndrome, there is a blockade to be a mild inflammation39 of the biliary tract, resulting in mild elevation
of the excretion of bilirubin into the canaliculi, caused by defects in the of direct bilirubin to levels of 2–3 mg/dL. A concomitant elevation of
adenosine triphosphate (ATP)-binding cassette (ABC) canalicular multi- alkaline phosphatase to levels of 200–300 IU/L is also observed.
specific organic anion transporter, MRP2/cMOAT/ABCC2 (Paulusma, In hepatitis, in which toxic destruction of hepatocytes is due to viral,
1997; Tsujii, 1999; Gottesman, 2001). This protein is a member of a family chemical, or traumatic causes, focal necrosis and/or cellular injury results
of approximately 100 different transporter proteins that share homology both in blocking conjugation of bilirubin and in excretion of conjugated

298

Direct Measurement of Natural Color

§ Used in the development of Icterus Index (1919)

§ Icterus Index
-  Muelengracht Method: dilute serum with NSS and compare
Laboratory Tests with 0.01% K2Cr2O7
-  Newberger Method: sodium citrate
§ Number of times the serum is diluted

L carotene, xantophyll II, hemoglobin

41 42

7
 9/27/13

Diazo-Colorimetric Procedure Diazo-Colorimetric Procedure

Reaction: Reaction (van den Bergh Test):
-  Bilirubin + DSA è Direct azobilirubin -  Bilirubin + DSA è Direct azobilirubin
-  Bilirubin + DSA + Accelerator è Total Azobilirubin -  Bilirubin + DSA + Accelerator è Total Azobilirubin

§ Evelyn and Malloy (1937) § Jendrassik and Grof (1938)

-  Reagents: -  Reagents:
-  Diazotized sulphanilic acid (DSA): -  Diazotized sulphanilic acid (DSA):
-  Sulphanilic acid -  Sulphanilic acid
-  Sodium nitrite -  Sodium nitrite
-  Caffeine sodium benzoate
-  50% Methanol
-  Sodium acetate
-  Sodium acetate
-  Ascorbic acid
-  Ascorbic acid

43 44

Advantages of Jendrassik-Grof Specimen considerations for

over Evelyn-Malloy Bilirubin Measurement
§ Insensitive to sample pH changes § Specimens: fasting, non-hemolyzed, non-lipemic
§ Insensitive to a 50-fold variation in protein concentration § Sources of errors: lipochrome, hemolysis, lipemia,
§ Adequate optical sensitivity even for low bilirubin exposure to light
concentration
Type of Bilirubin Normal Range Increased in:
§ Minimal turbidity and with constant serum blank
Conjugated 0 – 0.2 mg/dL Obstructive
§ Not affected by hemoglobin up to 750 mg/dL (0 – 3 umol/L) Jaundice
Unconjugated 0.2 – 0.8 mg/dL Hemolytic
(3 – 14 umol/L) Jaundice
Both conjugated 0.2 – 1.0 mg/dL Hepatocellular
and unconjugated (3 -17 umol/L) Jaundice

45 46

Urine Urobilinogen – Ehrlich’s Method Urine Urobilinogen – Ehrlich’s Method

§ Reagents § Sources of errors:

-  p-dimethyl aminobenzaldehyde (Ehrlich’s reagent) -  porphobilinogen, sulfonamides, procaine,
-  Ascorbic acid: reducing agent to maintain urobilinogen in 5-hydroxyindoleacetic acid
reduced state
-  NaCH3COO: stops the reaction and minimizes the § Specimen: 2 hour-fresh urine
combination of other chromogens
§ Product: red colored compound
§ Ehrlich’s unit of measurement

47 48

8
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Urine Urobilinogen Fecal Urobilinogen (Ehrlich’s aldehyde/

Watsons’ Reaction)
§ Reference range: § Aqueous extract of fresh feces + Fe(OH)2 + Ehrlich’s reagent
è red colored compound
- 0.1-1.0 Ehrlich units/2 hour or
0.5-4.0 Ehrlich units/day (0.868 mmol/day)
§ Reference values:
-  75-275 Ehrlich’s unit/100 g or 75-400 Ehrlich units/24 hours
Observation Inference Type of Jaundice
Pink/red color Increased UBG hemolytic
No pink/red color Decreased UBG obstructive

49 50

Clinical Significance of Urobilinogen Test for Bile Salts

§ Increased: hemolytic disease, defective liver cell
function (hepatitis)
§ Absence: biliary obstruction, hepatocellular disease
§ Hay Test
-  Sprinkle sulphur powder to 5 mL of urine
-  Interpretation:
-  Sulphur powder floats at the top: bile salts absent
-  Sulphur powder sinks to the bottom: bile salts present
(obstructive jaundice)

51 52

Test for Synthetic Function Test for Excretory Function

§ Measure the products of liver § Excretion of Foreign Dyes
- Total Protein - Measure % retention (serum sample)
- Albumin - Dyes are injected IV
- α-globulin § Bromsulphalein Test
- Prothrombin Time § Rose Bengal Test
- Prolonged: inadequate clotting factors

53 54

9
 9/27/13

Bromsulphalein Test Rose Bengal Test

§ Uses tagged I131

§ Radioactivity of the dye
Method Dose Time of Collection N.V. 686 SHINGLETON, TAYLOR TAYLOR
SHINGLETON, AND PIRCHER Annals of Surgery
686 AND PIRCHER Annals of Surgery
MayMay19661966
..... ....
......
.. ......... ..
...... ...... ... ....... ........... ... ....... .....

Rosenthal 2 mg/kg BW 5’ 50%-50

30’ 0-100%

Mc Donald 5 mg/kg BW 45’ +/- 5%

L BSP is toxic FIG. 1. Normal liver photoscan with FIG. 2. Liver photoscan in a patient with
Technetium4.m sulfur colloid. Laennec's cirrhosis.

FIG. 1. Normal liver photoscan

displacement with as demonstrated
of the liver, scans. photoscan
FIG. 2. Liver Table 3 shows
in a the
patient with disorders
extrinsic
Technetium4.m sulfur colloid.
in the anterior scan, made three dimen- Laennec's
adjacent to thecirrhosis.
liver which resulted in ab-
sional scan desirable to define the displace- normal scans showing displacement of the
the Occasionally
displacement ofment. a scan of the posterior
liver, as demonstrated liver. 3Results
scans. Table shows oftheinterpretation of photo-
extrinsic disorders
scans of patients with confirmed absence or
scan,of made
in the anterioraspect the liver was obtained for the
three dimen- adjacentpresenceto the liver
55 same reasons. of which resulted in ab-
disease indicated that 56 there
sional scan desirable to define the displace- normal were
scans14showing
errors of displacement
interpretation inof150thepa-
ment. Occasionally a scan of Results the posterior liver. Results of interpretation
tients, four being false positiveof photo-
and ten
aspect of the liver was obtained of liverfor scans offalse
thewere made patients with Overall
negative. confirmed absence
accuracy of inter-
or
Interpretations scans
same reasons. in all cases prior to confirmation ofpresence the of disease
pretation was 90indicated
per cent. Inthataddition
thereto
actual disease within or adjacent towere distinguishing between focal
the 14 errors of interpretation in 150 diffuse and pa-
liver.Results
232 photoscans were reviewed tients, and fourdiseasebeing
in the liver, the procedure provided
false information
positive and
additional valuable ten
regarding
correlated with the status of the liver in false
all negative. Overall accuracy of inter-
232 of
Interpretations liver scans
patients. possiblemade
It was were to confirmpretation
the the liver, including size, shape, position and
was 90 per cent. In addition to
configuration.
in all cases prior
presenceto confirmation
or absence of hepaticof theor perihe-
actual disease patic
within diseaseor by adjacent to the ordistinguishing
biopsy, laparotomy au- Figurebetween focal andof diffuse
1 is a photograph a normal
topsy in 150
liver. 232 photoscans were of these andThus, indisease
patients.
reviewed 82 in liver,Figure
liverthescan. the procedure provided
2 is a photograph of a
the of presence or absence ofadditional
dis- showing diffuse
scanvaluable liver disease
information (cirrho-
regarding
correlated withpatients,
the status the liver in all
ease in or contiguous to the liver following
232 patients. Itphotoscan
was possible to confirm the the liver,sis).
including 3 shows
Figure size, focal
shape, liver disease
position and
was not established, andconfiguration.
the (metastatic tumor). Figure 4 is a photo-
presence or absence
scans onofthese hepatic or perihe-
patients are not included. graph of a liver scan showing compression
patic disease byPatients
biopsy,withlaparotomy
abnormal scansor au-were classi-
1 is a photograph
Figuredownward and displacement of amedially
normalof
topsy in 150 offied
theseas having
patients. either diffuse
Thus, liver scan.
or localized
in 82 Figure
the liver is a photograph
in a2patient of a
with a right subdia-
disease within
patients, the presence or adjacent to the liver.
or absence of dis- scan showing
phragmaticdiffuse liverFigure
abscess. disease5 is(cirrho-
a photo-
Table lists

Detoxification Function Test

1 the types
ease in or contiguous to the liver following of diffuse liver dis- graph
sis). Figure 3 shows focal liver disease
of an anterior-posterior and lateral

Urine Bilirubin
eases which were associated with an ab- liver scan in a patient with pyogenic liver
photoscan wasnormal established,
not scan. Table 2 showsand the (metastatic
the confirmed tumor). Figure 4 is a photo-
abscess. Figure 6 is a photograph of the
scans on theselocalized
patientsdiseasesare not included.
associated graph ofliver
with abnormal a liver
scan in a showing
scan patient with compression
a large epi-
Patients with abnormal scans were classi- downward and displacement medially of
fied as having either diffuse or localized the liver in a patient with a right subdia-
1.  Foam Test: yellow foam (+) § Quick’s
disease within or adjacent to the liver.
Test
Table ortypesHippuric
1 lists the Acidgraph
of diffuse liver dis- Test
phragmatic abscess. Figure 5 is a photo-
of an anterior-posterior and lateral
eases which associated with an ab-
were liver scan in a patient with pyogenic liver
-  Patient
normal is given a with
Table 2 shows
scan.
localized diseases associated sodium
the confirmed benzoate
abnormal
abscess. Figure 6meal
is a photograph of the
liver scan in a patient with a large epi-
2.  Urine Color Inspection: brown to amber (+)
Hippuric Titrate with
Benzoic Conjugated
Sodium benzoate acid in standard
acid with glycine
urine alkali
3.  Fouchet’s Test or Harrison Spot Test
-  urine + BaCl2 è filter
-  precipitate + FeCl3 in TCA è green colored precipitate (+)

4.  Diazotization Test

-  Tablet test/Ictotest
-  Strip test

57 58

Enzyme Measurement The end…

§ AST: aspartate aminotransferase

§ ALT: alanine aminotranferase
§ ALP: alkaline phosphatase
§ GGT: gamma glutamyl transferase
§ 5’-nucleotidase
§ LD: lactate dehydrogenase

60

10