1. Investigations in Jaundice Dr Nikhil Bansal J.N.M.C.,Wardha

2. Investigations LFT CT Scan MRI Scan ERCP EUS Liver Biopsy 3. Liver Function Tests LFTs : What is the basis of abnormality ?Any other source ?Associated liver diseases ?How to investigate? 4. Aminotransferases AMINOTRANSFERASES : ASPARTATE AMINOTRANSFERASE (AST, formerly serum glutamic oxaloacetictransaminase or SGOT) ALANINE AMINOTRANSFERASE (ALT, formerly serum glutamic pyruvictransaminase or SGPT) 5. Elevation means Elevation : 2 to leakage from damaged cells Occursmany forms of liver disease but especially hepatocyte necrosis Eg. acute viral, chemical, ischaemia 6. ALT and AST ALT : relatively specific to liver AST :cardiac muscle, skeletal muscle,kidney,brain, pancreas, RBCs ISOLATED OR DISPROPORTIONATEELEVATION AST : Search for extrahepaticsources (cardiac or physical exercise) 7. ALT and AST Levels Usually < 300 in patients with alcoholichepatitis or biliary obstruction(bewaresuperimposed disease) Although sensitive indicator hepatocellularnecrosis frequently normal in cirrhosis oron-going disease 8. Lactate Dehydrogenase(LDH) Wide tissue distribution Elevated in skeletal, cardiac muscle, haemolysis,stroke, renal infarction and liver disease Useful : ischaemia, malignant infiltration 9. ALKALINE PHOSPHATASE Groupof enzymes (liver, bone, intestine, kidney,placenta, leukocytes, neoplasms) Increased production in tissues metabolic stimulation Bone / liver / intestinal 10. ALKALINE PHOSPHATASE Elevation of AP :Increased synthesis and release(not impaired biliary secretion) May take 1-2 days to be elevated Half-life 1 week Massive infiltrative disorders biliary obstruction(intra or extra) Focal obstruction with normal bilirubin 11. GAMMA GLUTAMYLTRANSPEPTIDASE (GGT) - Found in many extra-hepatic tissues - Not found in appreciable quantities in bone - Helpful confirming hepatic origin of Alk. Phos. - 1/3 of alcohol consumers > 80g/day have normal GGT and does not rise during binges 12. BILIRUBIN Serum bilirubin normally almost entirelyunconjugated (reflects a balance betweenproduction and excretion) 1. Unconjugated (increased production eghaemolysis or inherited defect in conjugation) 2. Conjugated : reduced hepatic excretionPrognostically useful (acute liver failure, alcohol)Levels > 500 unusual in absence renal failure andhaemolysis 13. Other LFTs PROTHROMBINTIME ALBUMIN 14. CHARACTERISTIC BIOCHEMICAL PATTERNS MARKED AMNOTRANSFERASE ELEVATION>1000:Drugs, toxins, ischaemia, viral,(auto-immune) 250-1000:Any type : viral, drug, auto-immune, Wilsons, 1AT, Over The Counter drugs. 15. MILD PERSISTENTAMNOTRANSFERASE ELEVATION Any type : Fatty liverDrugsAlcoholChronic viral hepatitisNeoplasmsHaemochromatosis 16. CHOLESTATIC LFTs DISPROPORTIONATE ALK PHOS(COMPARED TO Total bilurubin) Partial biliary obstruction, hepaticinfiltration, infection Confirm liver origin DISPROPORTIONATE Total Bilurubin(COMPARED TO ALK PHOS) : Haemolysisor Gilberts Syndrome 17. ISOLATED GGT Alcohol and Drugs ELEVATED ALK PHOS AND NORMAL GGT Rapid bone growth Bone disease Pregnancy 18. OTHER LABORATORY INVESTIGATIONS * LFTs * Prothrombin * Hepatitis B and C markers * Serum caeruloplasmin (if age < 60) * Immunoglobulins * Fasting Triglycerides and cholesterol * HbA1c * Ferritin * Tumour markers 19. Endoscopic Ultrasound 20. References Harrisons principles of internalmedicine. Davidsons Principles and practice ofmedicine. www.wikipeida.com