Investigations in jaundice

Investigations in jaundice by Dr NIkhil Bansal

1. Investigations in Investigations in
JaundiceJaundice
Dr Nikhil BansalDr Nikhil Bansal
J.N.M.C.,WardhaJ.N.M.C.,Wardha

2. InvestigationsInvestigations
L F TL F T
CT ScanCT Scan
MRI ScanMRI Scan
ERCPERCP
EUSEUS
Liver BiopsyLiver Biopsy

3. Liver Function TestsLiver Function Tests
LFT’s : What is the basis of abnormality ?LFT’s : What is the basis of abnormality ?
 Any other source ?Any other source ?
 Associated liver diseases ?Associated liver diseases ?
 How to investigate?How to investigate?

4. AminotransferasesAminotransferases
AMINOTRANSFERASES :AMINOTRANSFERASES :
ASPARTATE AMINOTRANSFERASEASPARTATE AMINOTRANSFERASE
(AST, formerly serum glutamic oxaloacetic (AST, formerly serum glutamic oxaloacetic
transaminase or SGOT)transaminase or SGOT)
ALANINE AMINOTRANSFERASEALANINE AMINOTRANSFERASE
(ALT, formerly serum glutamic pyruvic (ALT, formerly serum glutamic pyruvic
transaminase or SGPT)transaminase or SGPT)

5. Elevation means…Elevation means…
Elevation :Elevation :2º to leakage from 2º to leakage from
damaged cellsdamaged cells
Occurs many forms of liver disease Occurs many forms of liver disease
but especially hepatocyte necrosisbut especially hepatocyte necrosis
Eg. acute viral, chemical, ischaemiaEg. acute viral, chemical, ischaemia

6. ALT and ASTALT and AST
AALLT : relatively specific to T : relatively specific to liverliver
AST :cardiac muscle, skeletal muscle, AST :cardiac muscle, skeletal muscle,
kidney,brain, pancreas, RBC’s kidney,brain, pancreas, RBC’s
ISOLATED OR DISPROPORTIONATE ISOLATED OR DISPROPORTIONATE
ELEVATION AST : Search for extrahepatic ELEVATION AST : Search for extrahepatic
sources (cardiac or physical exercise)sources (cardiac or physical exercise)

7. ALT and AST LevelsALT and AST Levels
Usually < 300 in patients with alcoholic Usually < 300 in patients with alcoholic
hepatitis or biliary obstruction(beware hepatitis or biliary obstruction(beware
superimposed disease)superimposed disease)
Although sensitive indicator hepatocellular Although sensitive indicator hepatocellular
necrosis frequently normal in cirrhosis or necrosis frequently normal in cirrhosis or
on-going diseaseon-going disease

8. Lactate Dehydrogenase(LDH)Lactate Dehydrogenase(LDH)
Wide tissue distributionWide tissue distribution
Elevated in skeletal, cardiac muscle, haemolysis, Elevated in skeletal, cardiac muscle, haemolysis,
stroke, renal infarction and liver diseasestroke, renal infarction and liver disease
Useful :Useful :ischaemia, malignant infiltrationischaemia, malignant infiltration

9. ALKALINE PHOSPHATASEALKALINE PHOSPHATASE
Group of enzymes (liver, bone, Group of enzymes (liver, bone,
intestine, kidney,placenta, intestine, kidney,placenta,
leukocytes, neoplasms)leukocytes, neoplasms)
Increased production in tissues Increased production in tissues
metabolic stimulation Bone / liver / metabolic stimulation Bone / liver /
intestinalintestinal

10. ALKALINE PHOSPHATASEALKALINE PHOSPHATASE
Elevation of AP :Increased synthesis and release Elevation of AP :Increased synthesis and release
(not impaired biliary secretion)(not impaired biliary secretion)
May take 1-2 days to be elevatedMay take 1-2 days to be elevated
Half-life 1 weekHalf-life 1 week
Massive Massive ­­ infiltrative disorders biliary obstruction infiltrative disorders biliary obstruction
(intra or extra)(intra or extra)
Focal obstruction with normal bilirubinFocal obstruction with normal bilirubin

11. GAMMA GLUTAMYL GAMMA GLUTAMYL
TRANSPEPTIDASE (GGT)TRANSPEPTIDASE (GGT)
--Found in many extra-hepatic tissuesFound in many extra-hepatic tissues
--Not found in appreciable quantities in boneNot found in appreciable quantities in bone
--Helpful confirming hepatic origin of Alk. Phos.Helpful confirming hepatic origin of Alk. Phos.
--1/3 of alcohol consumers > 80g/day have normal1/3 of alcohol consumers > 80g/day have normal
 GGT and does not rise during bingesGGT and does not rise during binges

12. BILIRUBINBILIRUBIN
Serum bilirubin normally almost entirely Serum bilirubin normally almost entirely
unconjugated (reflects a balance between unconjugated (reflects a balance between
production and excretion)production and excretion)
1.1.Unconjugated (increased production eg Unconjugated (increased production eg
haemolysis or inherited defect in conjugation)haemolysis or inherited defect in conjugation)
2.2.Conjugated : reduced hepatic excretion Conjugated : reduced hepatic excretion
Prognostically useful (acute liver failure, alcohol) Prognostically useful (acute liver failure, alcohol)
Levels > 500 unusual in absence renal failure and Levels > 500 unusual in absence renal failure and
haemolysishaemolysis

13. Other LFTsOther LFTs
PROTHROMBIN PROTHROMBIN
TIMETIME
ALBUMINALBUMIN

14. CHARACTERISTIC CHARACTERISTIC
BIOCHEMICAL PATTERNSBIOCHEMICAL PATTERNS
MARKED AMNOTRANSFERASE MARKED AMNOTRANSFERASE
ELEVATIONELEVATION
> 1000:> 1000:Drugs, toxins, ischaemia, Drugs, toxins, ischaemia,
viral,(auto-immune)viral,(auto-immune)
250-1000: 250-1000: Any type : viral, drug, Any type : viral, drug,
auto-immune, Wilson’s, auto-immune, Wilson’s, aa1AT, Over 1AT, Over
The Counter drugs.The Counter drugs.

15. MILD PERSISTENT MILD PERSISTENT
AMNOTRANSFERASE ELEVATIONAMNOTRANSFERASE ELEVATION
Any type :Any type :Fatty liverFatty liver
 DrugsDrugs
 AlcoholAlcohol
 Chronic viral hepatitisChronic viral hepatitis
 NeoplasmsNeoplasms
 HaemochromatosisHaemochromatosis

16. CHOLESTATIC LFT’sCHOLESTATIC LFT’s
DISPROPORTIONATE ALK PHOS DISPROPORTIONATE ALK PHOS
(COMPARED TO Total bilurubin)(COMPARED TO Total bilurubin)
 Partial biliary obstruction, hepatic Partial biliary obstruction, hepatic
infiltration, infection Confirm liver origininfiltration, infection Confirm liver origin
DISPROPORTIONATE Total Bilurubin DISPROPORTIONATE Total Bilurubin
(COMPARED TO ALK PHOS) : Haemolysis (COMPARED TO ALK PHOS) : Haemolysis
or Gilbert’s Syndromeor Gilbert’s Syndrome

17. ISOLATED GGTISOLATED GGT
Alcohol and DrugsAlcohol and Drugs
ELEVATED ALK PHOS AND NORMAL GGTELEVATED ALK PHOS AND NORMAL GGT
Rapid bone growthRapid bone growth
Bone diseaseBone disease
PregnancyPregnancy

18. OTHER LABORATORY INVESTIGATIONS OTHER LABORATORY INVESTIGATIONS
**LFTsLFTs
**ProthrombinProthrombin
**Hepatitis B and C markersHepatitis B and C markers
**Serum caeruloplasmin (if age < 60)Serum caeruloplasmin (if age < 60)
**ImmunoglobulinsImmunoglobulins
**Fasting Triglycerides and cholesterolFasting Triglycerides and cholesterol
**HbA1cHbA1c
**FerritinFerritin
**Tumour markersTumour markers

26. Endoscopic UltrasoundEndoscopic Ultrasound

27. ReferencesReferences
Harrison's principles of internal Harrison's principles of internal
medicine.medicine.
Davidson’s Principles and practice of Davidson’s Principles and practice of
medicine.medicine.
 www.wikipeida.comwww.wikipeida.com