Investigations of Liver and Biliary tract 1 pptx - Liver and Biliary tract

Investigation of

Hepatobiliary Disease

Aims of investigations in patients with suspected liver disease:

Detect hepatic abnormality
Measure the severity of liver damage
Define the structural effects on the liver
Identify the specific cause
Investigate possible complications
Aims of Investigation:

Investigation of

Suspected
Liver disease
Determine
the severity &
Activity of Disease
Liver
Function Tests
Detection of
hepatic Abnormality
Biochemical
Tests
Specific etiological
Investigations
Liver
Biopsy
Investigations of the
Potential complications
of liver disease
Identification of structural
Lesions within the liver
Imaging
Coagulation
tests

Liver Function Tests used to assess Liver Disease
• Measurement
• Fluid
• Assessment
• Bilirubin
• Plasma
• Urine
• Transport
• Aminotransferases
• Plasma
• Hepatocellular damage
• Alkaline phophatase
• Plasma
• Biliary obstruction
• Gamma-Glutamyl transferase
• Plasma
• Enzyme induction
• Proteins (total & albumin)
• Plasma
• Synthesis
• Coagulation tests
• Plasma
• Synthesis

Notes
Bilirubin detected in the urine identifies conjugated hyperbilirubinemia & indicates hepatobiliary disease
Alanine aminotransferase (ALT, SGPT) is more specific for liver damage than aspartate aminotraferase (AST, SGOT).

• Enzyme combination

• Diagnostic likelihood

• Aminotrasferase

• Alkaline phosphatase
• Hepatocellular Jaundice
• Biliary Obstruction
• > X 6
• < X 2.5
• 90%
• 10%
• < X 6
• > X 2.5
• 10%
• 80%
• Other combinations

• No clear separation

Biochemical Tests in

Different Causes of Jaundice

Other biochemical tests

Hyponatremia
Occur in severe liver diseases
Multifactorial in etiology
Blood urea
B. urea may be reduced due to impaired hepatic synthesis
Increased B. urea found :
Following upper GIT bleeding
In hepatorenal failure, when associated with high serum creatinin

Hematological Investigations

Hb concentration, WBC & platelets counts may be normal
Normochromic normocytic anemia can reflect acute upper GIT bleeding due to:
Bleeding esophageal varices
Bleeding peptic ulcer (more common among those with chronic liver disease)
Hypochromic microcytic anemia secondary to chronic blood loss from:
Peptic ulcer
Portal hypertensice gastropathy
High erythrocyte MCV (macrocytosis):
Alcohol misuse
Target cells in any jaundiced patient
Rarely, erythrocytosis occurs in hepatocellular carcinoma due to ectopic secretion of erythropoietin

Leucopenia & thrombocytopenia in portal hypertension & hypersplenism
Leucocytosis in:
Cholangitis
Alcoholic hepatitis
Hepatic abscesses
Atypical lymphocytes are seen in infectious mononucleosis which might be complicated by acute hepatitis
Thrombocytosis:
Active GIT bleeding
Hepatocellular carcinoma (rare).
Hematological Investigations

Drugs increasing plasma GGT

Barbiturates
Carbamazepine
Ethanol
Glucocorticoids
Griseofulvin
Isoniazide
Meprobamate
Phenytoin
Primidone
Rifampicin

Tests to determine severity & activity of liver disease
These can :
give important information on the severity of both acute & chronic liver failure
Provide prognostic information in the above clinical situations
Biochemical tests:
Liver function tests
Albumin

Coagulation tests:

The liver synthesizes most coagulation factors
It requires vitamin K to activate factors II, VII, IX, X (1972)
Reduced plasma fibrinogen concentration & prolongation of prothrombin time occur in:
Severe liver damage
Prolonged biliary obstruction (associated with reduced absorption of vitamin K)
An increased prothrombin time is evidence for severe liver disease, provided that vitamin K (10 mg by slow i.v. injection) is given to exclude deficiency
Hypercoagulation can cause:
Hepatic venous thrombsis
Budd-Chiari syndrome
Tests to determine severity & activity of liver disease

Specific Etiological Investigations

• Disease
• Test
• Hemochromatosis
• Serum ferritin
• Serum iron, iron binding capacity, saturation
• Polymerase Chain Reaction (PCR) for genetic abnormality
• Wilson’s disease
• Serum ceruloplasmin
• Serum, urine, liver copper estimations
• Hepatitis A infection
• IgM anti-hepatitis A virus

• Hepatitis B infections
• Hepatitis B surface antigen (HBsAg)
• Hepatitis B e antigen (HBeAg)
• Hepatitis B viral DNA (HBV-DNA)
• Anti-hepatitis B core (anti-HBc)
• Anti-hepatitis B surface (anti-HBs)
• Anti-hepatitis B e (anti-HBe)
• Hepatitis C
• Anti-hepatitis C virus antibodies (various)
• PCR for hepatitis C viral DNA
Specific Etiological Investigations

• Hepatitis D infections

• Anti-hepatitis D (IgM & IgG)
• Hepatitis E
• Anti-hepatitis E (anti-HEV)
• Autoimmune chronic active hepatitis
• Serum immunoglobulins
• Serum anti-nuclear factor, anti-smooth muscle and liver, kidney, micorsomal (LKM) antibodies
• Primary biliary cirrhosis
• Serum immunoglobulins
• Serum antimitochondrial antibodies
Specific Etiological Investigations

Liver Biopsy
Liver biopsy can:
Confirm the severity of liver damage
Provide etiological information
Liver biopsy is relatively safe if the following conditions are met:
Cooperative patient
Prothrombin time < 4 seconds prolonged
Platelets count > 100 X109/l
Exclusion of:
bile duct obstruction
localized skin infection
advanced COPD
marked Ascites
severe anemia

Investigations of Complications of Hepatic Cirrhosis

• Complication
• Investigations
• Hepatic encephalopathy
• Investigations for any precipitating cause
• Psychometric tests
• EEG
• Sensory evoked potential
• Portal hypertension
• Upper GI endoscopy
• Barium swallow & meal
• Liver ultrasound
• Abdominal CT scan
• Wedged hepatic venous pressure
• Venography of hepatic vein

• Complication
• Investigations
• Ascites
• Ascitic fluid sampling (for protein concentration, WBC count, bacterial culture, cytological examination)
• Liver ultrasound
• Laparoscopy
• Renal failure
• Urine analysis
• Renal ultrasound
• Central venous pressure recording
• Renal biopsy
• Hepatocellular carcinoma
• α- fetoprotein
• Liver ultrasound
• Abdominal CT
• Hepatic angiogram
• Laparoscopy