LIVER FUNCTION

TESTS AND HOW

TO RELATE THEM
TO DISEASES
Dr. Abhiram kumar
 INTRODUCTION

LFTs are a set of basic investigations done in

all suspected hepatobiliary diseases.
They should be interpreted with the
background of clinical history and physical
findings to yield meaningful conclusions.
No single test alone is sufficient to provide
complete estimate of the function of liver.
 CLASSIFICATION

1)Tests of biochemical activity

a) Tests of liver cell injury

Alanine aminotransferase (ALT/SGPT)
Aspartate aminotransferase (AST/SGOT)
Lactate dehydrogenase (LDH)
b) Tests of cholestasis
Alkaline phosphatase
Gamma glutamyl transpeptidase
5-Nucleotidase
Bilirubin (total,conjugated)
Urine urobilinogen
Serum and urine bile acids
2) Tests of liver synthetic capacity
Albumin and other proteins
Prothrombin time
Serum ammonia
Plasma and urine aminoacids
Serum lipid profile
3) Tests of quantitative function
Galactose elimination Test
Breath tests
MEGX test
4) Imaging studies
Ultrasound scan
CT scan
MRI scan
Radioisotope scan
5) Histologic studies
 1.Tests of biochemical
activity
Transaminases

. The two enzymes which are sensitive

indicators of hepatocellular damage are
1)AST/SGOT
2)ALT/SGPT
They are released in to circulation by
hepatocellular necrosis
Normal value is 5-45 IU/L
 AST is a mitochondrial and cytosolic enzyme
present not only in liver but also in heart, skeletal
muscle, brain, pancreas, lung, RBC and kidney.
Hence whenever these tissues are acutely
damaged, AST will be increased. It has a long
serum half life of 48 hrs.
ALT is a cytosolic enzyme seen mainly in
hepatocytes and has a shorter half life of 18 hrs.
Hence an increased ALT is more specific and
sensitive for hepatocellular injury than AST.
 AST is relatively more specific for chronic
liver disease and alcoholic liver disease
and ALT for acute liver disease.
De Ritis ratio: In alcoholic hepatitis, the
AST:ALT ratio is always 2:1. The ratio is usually
<1 in patients with acute and chronic
nonalcoholic hepatitis.
 Maximum levels of transaminases are seen in
conditions causing extensive hepatocellular
necrosis like drug induced hepatitis, viral
hepatitis, ischaemic hepatitis, toxic hepatitis.
In acute hepatitis, Transaminases are 10 times
above normal. In chronic hepatitis and
cholestatic jaundice they are about 5 times the
normal
 Fluctuating levels of transaminases may be seen
in hepatitis C infection (yo-yo phenomenon)
A sudden fall in transaminases in a sick
jaundiced patient is indicative of bad prognosis
as seen in acute fulminant hepatitis.
In anicteric hepatitis and inapparent hepatitis
the only biochemical abnormality may be an
elevated ALT or AST.
 Hemodynamic changes like diarrhoea and vomiting
may lead to small transient elevation of transaminases
which may confuse the clinician.
Unexpected elevated transaminases may be
seen in Obesity
Diabetes mellitus
Alpha 1 antitrypsin deficiency
Asymptomatic chronic hepatitis B and C
Wilsons disease
 Diagnostic value of transaminases
The first laboratory abnormality detected in
early phase of viral hepatitis is elevated
transaminases.
In hepatitis, elevation of transaminases precedes that of
bilirubin by about one week. Thus transaminases may be
declining as serum bilirubin is increasing in uncomplicated
hepatitis.
During recovery phase of viral hepatitis, there is a steady
fall in level of transaminases.
Secondary elevation of transaminases or their
persistent elevation indicates recrudesence of
hepatitis or development of chronic hepatitis.
Absolute elevation is of little prognostic value
in predicting the outcome of acute hepatitis
 ALKALINE
Serum
PHOSPHATASE
alkaline phosphatase (AP) activity refers to
group of isoenzymes that hydrolyse organic
phosphate esters at alkaline pH to inorganic
phosphate and an organic radical.
Sources of AP
Liver - canalicular membrane
Bone - osteoblasts
Small intestine - brush border of enterocytes
Kidney - proximal convoluted tubules
Leukoytes
Placenta
 Bone isoenzyme is heat labile compared hepatic
AP which is relatively heat stable. They can also
be differentiated by polyacrylamide gel
electrophoresis.
The most practical method to decide whether a
high serum AP is due to liver disease is by
measuring another enzyme which rises in
cholestatic disease and that is more specific to
liver like GGT or 5-Nucleotidase.
Zinc is a cofactor for AP and in condition
causing zinc deficiency, AP may be reduced.
 Mechanisms that contribute to raised levels of AP are
1)regurgitation from hepatocytes
2) increased synthesis

Dissociated jaundice In incomplete biliary obstruction

or when intrahepatic obstruction is only partial, bilirubin
may be normal or only slightly elevated while AP is quite
high.This is seen in space occupying lesions like
metastasis.
 Diagnostic value of AP
serum AP is elevated in following conditions
1)elevated 5 times above normal in
cholestasis both intrahepatic and
extrahepatic.
2)lesser degrees of elevation, up to 3 times the
normal are seen in all types of liver
disorders.
3) moderate elevation of AP of hepatic origin
may be seen in disorders that do not directly
involve liver like a) stage I & II of hodgkin
disease b) myeloid metaplasia c) CCF
d) intraabdominal infection.
4) genetic certain families have isolated
increase in AP that is of genetic origin.
 Bone AP is high in growing children, also in
rickets, osteomalacia and osteogenic
deposits
of bone.

Normal value: 3-13 king angstrom units/dl

up to 100 IU/l
 GAMMA GLUTAMYL
TRANSPEPTIDASE

It is synthesized by epithelium of small bile

ductules and hepatocytes.
This is one of the most sensitive tests for
presence of hepatobiliary disease and similarly
absence of raised GGT correlates well with
absence of hepatic metastasis.
GGT levels are higher in biliary tract disease
and cholestasis than in hepatocellular disease.
 An elevated GGT is used to confirm that a raised AP
is of hepatobiliary origin. Hence it is a more
sensitive marker compared to AP.
The following drugs may elevate GGT giving rise to
false positive diagnosis of hepatobiliary disease
1) anticonvulsants like phenytoin, barbiturates &
valproate. 2) TCA 3) anticoagulants like
warfarin 4) antihyperlipidemics 5) OC pills 6)
analgesics.
 An isolated raise in GGT is an early indicator of
alcohol consumption in otherwise healthy
children.
Cholestatic disease with normal GGT are seen
in 1) PFIC type I & II
2) Benign reccurent intrahepatic
cholestasis
Normal value: 0 - 60 IU/L
 5 - NUCLEOTIDASE

This enzyme is found in liver, intestine, heart,

blood vessel & endocrine pancreas.
In liver, this enzyme is isolated in both
sinusoidal and canalicular plasma membrane.
It is elevated in hepatobiliary disease and
pregnancy but not in bone disease.
If it is elevated along with AP it can be
concluded that AP is that of hepatic origin.
Type of Transamina Alkaline
jaundice ses phosphatas
e
Hemolytic normal normal
jaundice
Hepatocellul >10 times <3 times
ar jaundice elevated elevated
Cholestatic <5 times >3 times
jaundice elevated elevated
 SERUM BILIRUBIN
Bilirubin, a tetrapyrrole pigment, is a breakdown
product of ferroprotoporphyrin IX.
Its level confirms jaundice, indicates the depth
and used to assess the prognosis.
Its level represents the balance between input
from production and hepatic removal of the
pigment.
Unconjugated hyperbilirubinemia is due to
overproduction or impaired uptake or conjugation
of bilirubin.
 Conjugated hyperbilirubinemia is due to
decreased excretion or backward leakage of the
pigment.
Serum bilirubin (S.Bb) is not a sensitive indicator
of hepatic dysfunction and may not accurately
reflect the degree of liver damage because an
increase in Serum albumin may induce a
temporary shift of bilirubin from tissue sites in to
circulation.
 Many labs still use spectophotometry to measure
S.Bb as direct or indirect fractions. This is based on
Vandenbergh reaction where Bb reacts with Ehrlichs
diazotised sulfanilic acid to produce chromogenic
compounds that can be detected colorimetrically.
Vandenbergh reaction (VR) can be used to
differentiate between direct and indirect Bb because
of different solubility properties of two pigments.
 In Direct VR, reaction is carried out in aqueous
medium, the water soluble conjugated Bb reacts to
gives direct reaction.
In Indirect VR, reaction is carried out in methanol.
The intramolecular hydrogen bonds of unconjugated
Bb are broken and both conjugated and unconjugated
Bb react giving a measure of total Bb level.
The unconjugated form is obtained by subtracting
direct from total bilirubin.
 HPLC helps to accurately estimate conjugated
and unconjugated bilirubin.
Normal S.Bb value: 0.1 - 1 mg %.
If congugated fraction is >15 - 20 % of total
Bb, patient has congugated hyperbilirubinemia
and if unconjugated Bb is >90%, patient has
unconjugated hyperbilirubinemia.
properties Unconjugate Conjugated
d Bb Bb
Water insoluble soluble
solubility
Lipid solubility soluble insoluble

Vandenbergh indirect direct

reaction
Binding to ++++ +
albumin
 URINE UROBILINOGEN
UBG is formed in terminal ileum and colon from
conjugated Bb by Clostridium ramosum, helped
by E.coli.
UBG excreted in stool is called stercobilinogen. It
is converted by colonic bacteria to stercobilin
which imparts the normal brown colour of stools.
Hence in cholestatic jaundice stools are pale as
Bb can not reach the gut and hence stercobilin is
not formed.
About 20% of UBG is reabsorbed and undergoes
enterohepatic circulation.
 Increase in UBG in urine is found in hepatitis as
damaged hepatocytes are not able to reexcrete
the UBG absorbed from gut. It is thus a good
index of hepatocellular dysfunction, often when
other tests are normal.
Urine UBG is increased in following conditions
1)hepatitis 2)malignant disease of liver 3)cirrhosis
4)hemolytic anaemia 5)circulatory failure
6)pyrexia 7)severe constipation.
 UBG is absent in following conditions
1)complete biliary obstruction
2)severe bilirubin glucoronyl transferase
deficiency as seen in CN syndrome type I.
3)severe diarrhoea
4)prolonged antimicrobial treatment
 URINE ABNORMALITIES IN
JAUNDICE
Type of Urine Urine
jaundice bilirubin urobilinog
en
Hemolytic nil +++
jaundice
Hepatocellul +++ +++
ar jaundice
Cholestatic +++ nil
 Tests of liver synthetic
Albumincapacity
and other
proteins
Hepatocytes manufacture a number of proteins,
which are released in to plasma like albumin,
fibrinogen, alpha 1 antitrypsin, haptoglobin,
ceruloplasmin, transferrin, prothrombin etc. Hence
reduced levels of these reflect a decline in synthetic
capacity of liver.
Of these, ceruloplasmin,fibrinogen,alpha 1
antitrypsin and haptoglobin are acute phase
reactants. Their serum levels may be raised when
the patient has acute hepatitis.
 SERUM ALBUMIN

The normal serum albumin is about 3.5 - 5 g%.

In liver disease, the fall in S.albumin concentration is
slow, as the serum half life of albumin is about 22
days. Hence, a low albumin is taken as a sign of
chronic liver disease, rather than acute disease.
A low S.albumin is seen in many non hepatic disorders
like nephrotic syndrome, PEM and protein losing
enteropathy. Nevertheless, hypoalbuminemia is a
excellent indicator of severity of chronic liver disease.
 SERUM GLOBULINS

Serum IG are produced by stimulated B-

lymphocytes hence they do not directly test
liver function.
In chronic liver disease, the function of
reticuloendothelial cells of liver is impaired.
Hence bacteria can not be destroyed and they
reach the circulation, stimulating the B-
lymphocytes to produce IG.
 The gamma globulin level is increased in cirrhosis
due to increased production. The increased
number of plasma cells in bone marrow may be
the source.
Elevation of specific IG
- IgG in chronic active hepatitis and cryptogenic
cirrhosis.
- IgM is markedly elevated in primary biliary
cirrhosis and to some extent in chronic active
hepatitis and cryptogenic cirrhosis
- IgA is markedly elevated in alcoholic cirrhosis
and to some extent in cryptogenic cirrhosis and
primary biliary cirrhosis.
 BILE ACIDS
The liver is the only organ that can synthesize
bile acids.
The primary bile acids, cholic acid and cheno
deoxycholic acid are formed from cholesterol.
Their synthesis is regulated by amount of bile
acids returning to liver in enterohepatic
circulation.
The colonic bacteria convert primary bile acids to
secondary bile acids, mainly deoxycholic acid
and a very little lithocholic acid, by 7 alpha
dehydroxylation.
 Tertiary bile acids like ursodeoxy cholic acid are
produced in liver by epimerization of secondary
bile acids.
The bile acids are conjugated in liver with the
aminoacids glycine and taurine. This prevents
reabsorption in biliary tree and small intestine but
permits conservation by absorption in terminal
ileum.
The absorbed bile salts enter the portal venous
system and reach the liver where they are taken
up actively by hepatocytes.
 The bile salts are reconjugated and excreted in
bile. This entero hepatic transport of bile salts
takes place 2-15 times per day, which helps to
prevent the loss of bile salts.
The maintenance of normal S.bileacids
depends on hepatic blood flow, hepatic
uptake, secretion of bile acids by liver and
entero hepatic circulation.
 Serum bile acids can be determined by 3 methods
1)Gas liquid chromatography
2)Enzymatic assays
3)Radioimmunoassay
S.bileacids measured by Radioimmunoassy may
be the best screening test for liver disease.
Elevation of S.bileacids is specific for hepatobiliary
disease.
 PROTHROMBIN TIME

Liver plays three roles in control of coagulation:

1) Production clotting factors except von
Willebrand factor, which is synthesized in
megakaryocytes and vascular endothelial cells.
2) Clearance of activated factors from circulation.
3) Production and breakdown of all factors integral
to fibrinolysis like plasminogen and plasminogen
activator.
 PT is measure of time it takes for prothrombin to
be converted to thrombin in the presence of tissue
extract, calcium ions and activated factors V,
VII,X.
The result of reaction that produced thrombin is
expressed in seconds or as a ratio of plasma PT to
a control PT.
Normal values are 12-13 seconds.
Prolongation of more than 2 sec is considered
pathologic and values >3 sec above normal
indicate risk of bleeding.
 Activated factor VII is the key enzyme of extrinsic
pathway as it has shortest half life. Patient with
early liver disease may present with an isolated
prolonged PT.
A prolonged PT also suggests a poor prognosis in
chronic liver disease, this along with decreasing
serum albumin is the most important parameter
to decide on liver transplantation
 In a patient with liver disease PT may also
prolonged due to non hepatic causes other than
vitamin K deficiency like DIC.
Factor VIII is also synthesized from non hepatic
sources like vascular endothelium hence its level is
usually normal in liver disease, unless it is being
consumed as in DIC. Thus factor VIII level may help
to differentiate hemorrhage due to severe liver
disease alone from that due to accompanying DIC.
 INTERNATIONAL NORMALIZATION RATIO (INR)
This system standardizes the PT for different
thromboplastin reagents thus providing a universal
standard by which to compare any given lab result
with that of WHO standard.

ISI

INR = (patients PT /
normal PT)
ISI = International sensitization index (provided with
each batch of thromboplastin reagent)
Liver biopsy is contraindicated if INR is >1.3
INR helps to monitor patients on warfarin therapy
 Advantages of using INR system
1)Easier, smoother regulation of anti - coagulation.
2)Travelling patients will have a standard,
regardless of lab used.
3)Standardization of laboratory and research
efforts.
4)Reduced risks of complications associated with
higher doses of anticoagulants.
 USES OF PT
1)It helps to differentiate cholestatic from
hepatocellular jaundice.
2)It is not a sensitive index of liver disease, as
even with severe form of cirrhosis, it may be
normal or slightly prolonged.
3)It is of high prognostic value especially in acute
hepatocellular jaundice.
4)A prolonged PT is not specific for liver disease
as it may be seen in congenital deficiencies of
coagulation factors and also in acute conditions
like DIC and ingestion of drugs that effect
prothombin complex.
 SERUM AMMONIA
The concentration of ammonia in blood is regulated by
balance of its production and clearence.
It is produced in colon by action of bacterial urease on
dietary proteins and aminoacids.
Ammonia is converted by liver in to urea and then into
glutamine by urea cycle.
The liver removes 80% of portal venous ammonia in a
single pass.
Normal levels of s.ammonia is 11-35 micro moles/L
In chronic liver disease and portal hypertension ,large
amounts of ammonia bypass liver and reach brain,
contributing to hepatic encephalopathy.
However s.ammonia and level of hepatic encephalopathy
have a poor correlation.
 SERUM LIPIDS AND
LIPOPROTEINS
Lipids and lipoproteins are mainly synthesized in
liver except chylomicrons, which are synthesized in
intestine.
Liver diseases significantly affect serum lipids and
lipoprotein levels.
Serum cholesterol is increased in cholestatic
jaundice. Skin xanthomas develop if elevated 5
times above normal.
An abnormal lipoprotein, Lipoprotein X is synesized
in biliary atresia and neonatal hepatitis. Following
cholestyramine therapy, level decreases in
neonatal hepatitis, where as continues to be high
in biliary atresia.
 TESTS OF QUANTITATIVE
FUNCTION
These tests are complex and are done only in
research labs. These include
1)Galactose elimination test - galactose is
taken up by liver and converted to galactose I
phosphate by glactokinase, which is the rate
limiting reaction in galactose elimination from
blood. Galactokinase activity depends on
functional liver mass. Hence galactose
elimination gives an estimate of functional
hepatic cell mass.
2)Breath test Aminopyrine labelled with c14 is
given orally. It is metabolised by cytochrome p-
450 dependent demethylation to co2 in only liver.
samples of 14co2 are collected from the mouth for
2 hrs. The expired 14co2 correlates with rate of
disappearence of radioactivity from plasma. The
test reflects the residual functional microsomal
mass and viable hepatic tissue.
3)MonoEthylGlycineXylinide test (MEGX Test) -
MEGX is the main metabolite of Lignocaine formed
in hepatocyte microsomes by cytochrome
p450dependent demethylation. Lignocaine is
given IV and serum MEGX is measured at 15 min
and 30 min. Its level is decreased in cirrhosis
compared to control. MEGX test is useful to assess
the quality of organ donors. It is much superior to
conventional LFT in predicting graft survival.
 RADIOLOGY
PLAIN RADIOGRAPH OF ABDOMEN - It will give
an indication of size of liver and spleen. However
it is rarely of diagnostic value and hence not used
frequently.
ULTRASONOGRAPHY OF ABDOMEN - It
provides information about size of liver, spleen,
pancreas, kidney and gallbladder. It detects gall
stones, tumors, hemangiomas, abscess and cysts
with in liver. It allows targeting of lesions for liver
biopsy.
 A small or absent gallbladder after fasting
suggest either severe intrahepatic cholestasis or
biliary atresia in a neonate. An enlarged
gallbladder may suggest primary sclerosing
cholangitis.
CT SCAN it is helpful for detection and biopsy of
hepatic tumors and space occupying lesions. IV
contrast causes enhancement of vascular lesions
and wall of abscesses and helps in differentiation
of tumors from other solid masses.
 ERCP - A fibreoptic duodenoscope is passed in
to 1st part of duodenum, ampulla of vater is
identified, the pancreatic and biliary ducts are
cannulated and contrast is injected. This is very
useful in evaluation of extrahepatic liver disease
in older children like choledochal cysts, PSC and
chronic pancreatitis. It is technically very difficult
in neonatal cholestsis.
It can also be used to remove CBD stones and
for insertion of biliary stents.
 Percutaneous Transhepatic Cholangiography
(PTC) - It is useful for identification of biliary
disease, if intrahepatic bileducts are dilated
secondary to obstruction and ERCP is impossible
or unsuccessful. A thin needle (Chiba needle) is
passed through liver, the bile ducts or gallbladder
is punctured and radiological contrast is injected.
External drainage of biliary tree, dilatation of
biliary strictures and the introduction of biliary
stents are all possible using this procedure.
 Hepatobiliary Scintigraphy
-The development of soluble radioisotopes (technicium
trimethyl I bromo iminodiaceic acid) which are taken up
well by hepatocytes despite elevated Bb levels have
been utilized to either hepatic uptake or biliary
excretion.
-Pretreatment with phenobarbitone (5mg/kg) for 3-5
days prior to investigation improves hepatic uptake of
isotope.
-It is most useful in assessment of biliary excretion in
DD of neonatal cholestasis. Under normal conditions
biliary excretion is completed in 4 hrs.
-Delayed excretion or no excretion after 24hrs
suggests severe intrahepatic cholestasis or EHBA.
-It is of some value in diagnosis of hepatic vein
obstruction (Budd Chiari syndrome) as poor uptake of
liver is demonstrated in most of liver except in
caudate lobe which has got separate venous drainage.
 ANGIOGRAPHY Visualisation of coeliac axis,
hepatic and splenic blood vessels is obtained by
femoral artery catheterization and injection of
radiological contrast. This techniqhe has 2 parts.
-Arterial phase, which provides information
about coeliac axis, hepatic and splenic artery
abnormalities, vascularization and anatomy of
hepatic tumors, hepatic hemangiomas or detection
of hepatic artery thrombosis.
-Venous phase, provides information about
patency of portal, splenic and superior
meseteric veins and the presence of portal
hypertension and identification of mesenteric,
esophageal or gastric varices.
-Femoral artery spasm or thrombosis is an
occasional side effect, but rarely requires
operative treatment.
 Splenoportography here splenic and portal
radicles are visualised by injection of contrast into
spleen, it has largely been replaced by hepatic
angiography.
MRI It has now replaced hepatic angiography as
best way to stage or diagnose hepatic tumors and
to identify their vascular supply.
-It may provide valuable information about liver or
brain consistency and storage of heavy metals.
The recent development of MRCP, in which
both intra and extrahepatic biliary ducts, and
also the pancreatic duct may be detected,
may replace ERCP as a diagnostic
investigation.
 LIVER BIOPSY

The diagnosis of most liver diseases requires

histological confirmation and thus liver
biopsies are a routine procedure in specialist
centres.
Indications
unexplained hepatomegaly
unexplained jaundice
unexplained elevation of liver enzymes
cholestatic liver disease biliary atresia and
neonatal hepatitis
cirrhosis
chronic hepatitis
drug related hepatitis
infections of liver like TB
enzyme analysis for IEM
copper estimation in wilson disease when other
tests are equivocal
post liver transplantation to assess acute
rejection.
 Contraindications
PT >3sec or prolonged or INR >1.3
thrombocytopenia - PLC <60,000
presence of grossly dilated bile ducts
angiomatous malformations of liver
hydatid cysts
severe ascites
 Complications
hemorrhage
intrahepatic hematoma
hemobilia
pleurisy and perihepatitis
development of AV fisthula
biliary peritonitis
puncture of other organs
infection
 Thank
you