Enzymes Liver Pancreas

Cell destruction Cell Proliferation Increases synthesis oxidoreductases, transferases, hydrolases, lyases, isomerases, ligases Substrate concentration Enzyme concentration pH Temperature Cofactors inhibitors

Elevation of enzyme levels caused by:

Enzyme Classification: 6 classes:

Factors that influence enzymatic reactions 6

Enzyme reactions requires: 4 Zero Order difference in rate? Why?

1.Enzyme 2.Substrate 3.E-S complex 4.End Product the at nearby concentrations of substrate is almost negligible At these concentrations almost all of the enzyme molecules are bound to substrate and the rate is independent of substrate, zero order. At substrate concentrations near point A the rate appears to be directly proportional to substrate concentration At the substrate concentration exactly half the enzyme molecules are in an ES complex at any instant and the rate is exactly one half of Vmax concentration of substrate that gives "halfmaximal activity". if enzyme is elevated that all substrate is consumed early in reaction. Then the rate change is minimal = Errors sudden decrease in reaction rate, may indicate that the patient sample containing a enzyme level requires a dilution or decreased amount. Lipase: Triglyceride substrate Omylase: Starch substrate Elevated in liver and bone disorders Normal elevations in children and during pregnancy. 1

reaction rate - first order

Vmax = Point B

Constant Km =

Fixed Time problem

Kinetic problem Acute pancreatitis enzymes

Alkaline Phosphatase

Enzymes Liver Pancreas

Acid Phosphatase Elevated in prostatic cancer Tested for as confirmation in rape cases if found in vaginal fluid fraction of bilirubin covalently bound to albumin; in conventional methods it is measured as part of conjugated bilirubin. Because of its covalent bond during the recovery phase of hepatocellular jaundice it may persist in the blood for a week or more after urine clears. ALT- alanine transaminase AST - aspartate transaminase GGT - gamma-glutamyltranspeptidase Alkaline phosphatase Aldolase 1.Alk PO4

delta bilirubin

Liver function evaluated with enzyme testing

1.Which is helpful in diagnosing bone disease? 2.Which enzymes are helpful in diagnosis of muscle disorders? 3.Which enzymes tests for hepatic function? 4.Which one enzyme is most sensitive for all types of liver disease? 5.Is AST or ALT more specific for liver disease? 6.Which is sensitive indicator of alcoholism? first organ to encounter nutrients, vitamins, drugs, toxic agents etc. Most common liver injury is due to

2.CK, AST, LD, aldolase

3.ALT,AST, alkaline PO4 4.GGT 5.ALT is primarily found in liver & RBCs

6.GGT Liver viruses (hepatitis). 1. Synthetic and Metabolic 2. Excretory 3. Detoxification and protective 4. Hematology/Coagulation

FUNCTIONS OF LIVER

CATEGORIES of LIVER DISEASE (amyloid, neoplasm) 2

Enzymes Liver Pancreas

Cirrhosis: Inflammation of the liver: scaring and abnormal architecture of the liver Alcohol is common cause Autoimmune, viral, drugs Tumors: uncommon in US but common in other cultures for unknown reasons. Reyes Syndrome: death from liver destruction following viral infection, associated with aspirin use. Drug Induced: Most common fatty liver (vacuoles of fat) drugs

LIVER DISEASES 4 categories Most Common?

Steatosis

HEPATOTOXIC AGENTS many Halothane

Necrosis means neoplasia BILIRUBIN Conjugated (water soluble) bilirubin is excreted from liver into the removes the glucuronide from bilirubin and reduces bilirubin to

premature death of cells in living tissue The formation or presence of a new, abnormal growth of tissue. bile.

urobilinogen.

excreted in

2 ways how?

urine or oxidized to form urobilin and excreted in feces.

turns color which gives feces and urine its color. BILIRUBIN METABOLISM Excreted as: 2 chemicals? Where? stays attached until the albumin molecule is turned over, but measures as conjugated 3

Delta bilirubin

Enzymes Liver Pancreas

Clinical manifestation of hyperbilirubinemia Icterus and mucous membranes Kernicterus: blood brain barrier < 1 mg/dL (hemolytic) unconjugated hyperbilirubinemia; no bilirubin in urine defective conjugation; transport failure; hepatocellular damage or necrosis inability to transport conjugated bilirubin out of liver; obstruction of common bile duct by gall stones, neoplasms, spasms or stricture. HYPERBILIRUBINEMIA jaundice with yellow skin and sclera (2.5 - 5.0 mg/dL). 1. Overproduction 2. Impaired uptake by liver cells 3. Defects in the conjugation reaction 4. Reduced excretion into the bile 5. Obstruction to the flow of bile (1) Overproduction: due to excess RBC destruction, rate of hemolysis exceeds livers ability to clear bilirubin. Almost all unconjugated. (hemolytic anemia, sickle cell disease). (2) Impaired Uptake by Liver Cells: drugs block bilirubin uptake into liver hepatocytes. (3) Defective Conjugation (4) Reduced Excretion: Damage to liver cells, hepatitis, cirrhosis, drug induced. Conjugated bilirubin rises. (5) Obstruction: Mechanical obstruction of bile flow, gallstones in bile duct Mostly conjugated bilirubin rises. decrease of bilirubin transport into hepatocytes deficiency of UDPG- transferase Acquired: drug inhibits the enzyme Neonatal jaundice: the enzyme is not fully developed yet 4

JAUNDICE 2 kinds

total bilirubin = normal Classification of Jaundice Prehepatic Hepatic Jaundice

Posthepatic Jaundice

BILIRUBIN IN BLOOD 2 causes

Defective Conjugation Gilberts syndrome Crigler-Najjar syndrome Defective Conjugation Non-inherited

Enzymes Liver Pancreas

BILIRUBIN TERMINOLOGY Total Bilirubin = All forms of Bilirubin= Direct + Indirect+ Delta water soluble conjugated Bilirubin diglucuronide and delta Bilirubin (albumin bound) not water soluble alcohol soluble requires accelerator unconjugated Bilirubin toxic - 1.0 mg/dL -2 days) 3.4 11.5 -5 days) 1.5 12.0 Direct 0 - 0.2 mg/dL liver disease or bile ducts Decreased secretion into canaliculi hepatitis and/or drugs Decreased drainage stones in gall bladder carcinoma drugs tumors cirrhosis RBC hemolysis Inhibition of transport into hepatocyte by drugs Decreased conjugation Neonatal jaundice Inhibition of enzyme by drugs Gilbert Syndrome UROBILINOGEN metabolism. Bacteria in intestines converts urobilinogen into urobilin, a brown pigment. hemolytic disease and defective liver-cell function (hepatitis)

Direct Bilirubin =

Indirect Bilirubin =

BILIRUBIN REFERENCE INTERVALS -2 days) -5 days) Direct Elevated conjugated implies

Conjugated Elevated (cholestasis) In the liver 2 categories of reasons

Unconjugated Elevated In the liver 3 categories of reasons

Enzymes Liver Pancreas

biliary obstruction. purple color formation with Ehrlichs reagent (pdimethylaminobenzaldehyde). aid absorption of cholesterol and triglycerides Liver Proteins Transthyretin Ceruloplasmin Alpha1 antitrypsin Haptoglobin Beta2 microglobulin Transferrin Alpha fetoprotein (Transports/ binds iron) (Copper carrier) (Acute phase protein) (Transports/ binds free Hb) Bile Acids (Prealbumin:nutritional indicator)

(early liver cancer marker)

ALBUMIN Chronic Hepatitis Acute Hepatitis

hepatocytes as a marker of general liver function. -21 days

INCREASED ALBUMIN In 4?

Albumin Normal Range Transthyretin (prealbumin) RI

3.5 5.5 g/dL 18 - 22 mg/dL 6

Enzymes Liver Pancreas

AST & ALT: OTHER FACTORS Hemolysis Age/ Gender Diurnal Variation Race Exercise Body weight Muscle injury AST Reference Range ALT Reference Range 5-30 U/L

-50 then decreases

> ALT

6-37 U/L

Less than 1:1 viral hepatitis nonalcoholic steatohepatitis Greater than 1:1 (2:1, 3:1) chronic alcohol-induced liver damage (AST rarely more than 8x normal; ALT seldom more than 5x; maybe normal)

AST:ALT ratio

ALT

Male: 10-40 U/L Female: 7-35 U/L

ALKALINE PHOSPHATASE Factors effecting ALP

inhibits enzyme activity -3 X - no effect

ALKALINE PHOSPHATASE REFERENCE INTERVALS

44 to 147 IU/L Bile Duct Obstruction gall stones, surgery, cancer Bile Duct Disease primary biliary cirrhosis Drug-Induced cholestasis Liver Infiltration cancer, fungus, sarcoidosis may give highest values 7

MARKEDLY ELEVATED ALP (Normal or slightly elevated AST ALT)

Enzymes Liver Pancreas

high concentrations of kidney and liver but also pancreas and intestine GGT -Transferase from liver.

disease Reference Ranges ALT AST ALP GTT - 37 U/L female - 30 U/L - 90 U/L age important - 45 U/L male 5 30 U/L Female

AMMONIA (NH3)

Elevated in blood when liver failure levels low in Serum Encephalopathy, or damage to nerves in the brain, may be consequence of high ammonia (up to 5x)

GASTRIN hormones, and enzymes Zollinger-Ellison syndrome : Gastric-producing tumor leading to peptic ulcers, gastric hypersecretion; elevated gastrin Acute Pancreatitis Blockage of pancreatic duct with gallstones Alcohol excess Physical Trauma Chronic Pancreatitis Gall Bladder disease Alcoholism Pancreatic Cancer 4th most frequent form of fatal cancer 5 year survival <5% Pancreatic Insufficiency Cystic Fibrosis Chronic Pancreatitis

Pancreatic diseases

Enzymes Liver Pancreas

AMYLASE particularly acute pancreatitis

AMYLASE: Testing METHODS

formed Amyloclastic: measure decrease in starch substrate from dye-labeled substrate Hydrolyzes triglycerides

LIPASE earlier and persist longer Titrimetric: olive oil substrate; titrate fatty acids using pH indicator Turbidimetric: measure decrease in turbidity due to hydrolysis of substrate coupled with enzymatic reaction

LIPASE: Testing METHODS

Fecal Fat analysis Other pancrease test

mutations in a gene located on chromosome 7. Causes production of thick mucus due to faulty transport of Na and Cl within cells lining lungs and pancreas. Mucus obstructs pancreatic secretions from reaching duodenum Manifestations: intestinal obstruction, pulmonary infections, malabsorption

CYSTIC FIBROSIS

Enzymes Liver Pancreas

Symptoms: salty-tasting sweat; persistent coughing, wheezing or pneumonia; poor weight gain; bulky stools Treatment: vigorous percussion on back and chest; antibiotics; nutritional supplementation; Gene Therapy

CYSTIC FIBROSIS Symptoms Treatment:

CYSTIC FIBROSIS DIAGNOSIS SWEAT CHLORIDE ANALYSIS CONSIDERED MOST RELIABLE SINGLE TEST FOR DIAGNOSIS OF CYSTIC FIBROSIS Elevated sweat sodium and chloride (>60 mmol/L) in cystic fibrosis Iontophoresis, using drug pilocarpine to induce sweat Sweat is collected on preweighed gauze Elevated sweat sodium and chloride (>60 mmol/L) in cystic fibrosis Iontophoresis, using drug pilocarpine to induce sweat Sweat is collected on preweighed gauze Chloride/ Na is measured d-Xylose: pentose sugar not normally in blood Ability to absorb D-xylose helps in diagnosing malabsorption problems in intestine vs pancreatic insufficiency Test Fast, void in AM, drink d-Xylose and water Collect blood at 2 hours, and Urine collected after 5 hours

SWEAT CHLORIDE ANALYSIS

Tests of Intestinal Function D-Xylose Absorption Test

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