Liver Function o Principal pigment in bile

o Major metabolite of heme (found in hemoglobin (80%), myoglobin &

Liver cytokines)
– Largest and most versatile organ in the body o Production of bilirubin: 250-350 mg/day
– Consists of 2 lobes separated by a falciform ligament
o Right lobe is 6x larger than the left • Metabolism of bilirubin
– Weighs 1400 to 1600 g in a normal adult a. Hemoglobin = heme + globin
– Color: reddish brown • Haptoglobin – protein carrier of hemoglobin
– Located under the diaphragm in the RUQ of the abdomen o ↑ RBC destruction, ↓ haptoglobin
– Has an abundant blood supply from the hepatic artery and portal vein • Globin – recycled in the liver
o 15 mL/min of blood supply b. Heme = Fe + protoporphyrin heme
• Hemopexin – carrier of heme
• 2 Major Vessels o ↑ heme, ↓ hemopexin
1. Hepatic artery – 20% of blood supply • Transferrin – transporter of Fe
• provides the most of the O2 requirement c. Protoporphyrin heme à biliverdin à unconjugated bilirubin
2. Portal vein !"#$%&'
• Transports the most recently absorbed materials from the intestine to the • Unconjugated bilirubin liver
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liver d. Unconjugated bilirubin conjugated bilirubin
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• Conjugated bilirubin intestines
• Structural Units 78 #!-25.&!
1. Lobule e. Conjugated bilirubin Urobilinogen (colorless)
.56$-56
• 1-2 nm in diameter • Stercobilin
• Structural unit of the liver •
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Urobilin (brown-orange)
• Small branches that form a vascular network f. Urobilin – responsible for the brown coloration of stool
2. Sinusoids • 50-250 mg urobilin excreted per day
• Vascular spaces lined by endothelial cells and Kupffer’s cells • 1-4 mg urobilinogen excreted in urine per day (normal to have
o Kupffer’s cells – phagocytic macrophages urobilinogen in urine)

• Functions Bilirubin
1. Synthetic function • Orange-yellow pigment derived from hemoglobin degradation
• Protein, lipid, carbohydrate synthesis • Mainly transported by albumin
2. Detoxification function and drug metabolism
• Detoxification of ammonia Forms
3. Excretion function Bilirubin 1 Bilirubin 2
• Excretion of bilirubin
• Unconjugated bilirubin • Conjugated bilirubin
• Non-polar • Polar
• Physiology
• Water insoluble • Water soluble
A. Excretion of bile
• Indirect bilirubin • Direct bilirubin
• Bile comprises of:
• Hemobilirubin • Cholebilirubin
1. Bile acids and salts
• Bile acids – conjugated with amino acids (Glycine, Taurine)
Disorders of Bilirubin Metabolism
2. Bile pigments (bilirubin esters)
1. Jaundice
3. Cholesterol – digestion and absorption of lipids
• Yellowish discoloration of skin and sclera
4. Other substances excreted from the blood
• Increased bilirubin concentration in blood à pigments deposited in sclera of eyes,
• Total bile production: 3 L/day
skin à jaundice or icterus
o 500-600 mL bile enters duodenum per day
B. Metabolic function of the liver • Retention of bilirubin
• Bilirubin • Upper limit: 1.0-1.5 mg/dL (overt jaundice)
 • Types
Pre-hepatic Hepatic Post-hepatic 6. Jaundice of the Newborn
• Excessive amount of • Impaired cellular uptake • Impaired excretion of • Deficiency in the enzyme glucoronyl transferase
bilirubin • Defective conjugation bilirubin • Lucey-Driscoll Syndrome
• Characterized by • Abnormal excretion of • Biliary obstructive o Exposure of breastfeeding infants to inhibitors of bilirubin conjugation present
unconjugated bilirubin disease in breastmilk
hyperbilirubinemia • Rapid buildup of unconjugated bilirubin

2. Gilbert’s Syndrome Serum

• Most common, inherited Type of Jaundice Total Conjugated Unconjugated
• Associated with reduced activity of bilirubin UDPG-T Bilirubin bilirubin bilirubin
• Total bilirubin is about 2-3 mg/dL Pre-hepatic ↑ = ↑
• Characterized by intermittent unconjugated hyperbilirubinemia in the absence of Hepatic
hemolysis • Gilbert’s ↑ = ↑
• Asymptomatic but may have mild icterus • Crigler-Najjar ↑ ↓ ↑
• Laboratory investigation: • Dubin-Johnson ↑ ↑ =
o Phenobarbital – used to decrease bilirubin level in patients with Gilbert’s • Rotor ↑ ↑ =
syndrome • Jaundice of the ↑ = ↑
o Bilirubin levels in fasting state and with the use of phenobarbital newborn
Post-hepatic ↑ ↑ ↑
3. Crigler-Najjar Syndrome
• Inherited, severe deficiency of bilirubin UDPG-T
Specimen
• Types
• Serum or plasma; urine
Type 1 Type 2
Serum Plasma
• No enzyme activity in the liver • Enzyme activity is 10%
• Fluid obtained when coagulated blood • Fluid obtained when anticoagulated
• Conjugated bilirubin is not formed • Some conjugated bilirubin is has been centrifuged blood has been centrifuged
• Bile is colorless formed
• Anticoagulants are not needed • Anticoagulants are needed
• Affected infants: kernicterus • Less severe form
• Fibrinogen is absent • Fibrinogen is present
• Basal ganglia is damaged: uncontrollable shaking, muscle rigidity, involuntary • Takes longer time to prepare • Does not need standing: could be
muscle control • Most preferred part of blood used in centrifuged as soon as it has been mixed
checking blood groups and diagnosis of thoroughly
4. Dubin-Johnson Syndrome diseases • Delivered to patients who lack blood
• Associated with impaired liver handling of conjugated bilirubin and other pigments cells
o Excretion is defective
o Ability of liver to uptake and conjugate is normal • Fasting sample: to avoid lipemia
• Defect in canalicular multispecific organic anion transfer (cMOAT) • Avoid hemolyzed samples – will cause false decrease in Jendrassik-Grof medthod
• Results in increased plasma conjugated bilirubin, thus causing jaundice • Stored in the dark
o Total bilirubin: 2-5 mg/dL Temperature Stability
• Liver has intense dark pigmentation due to accumulation of lipofuscin pigment
Room temperature 2 days
4°C 1 week
5. Rotor Syndrome
• Similar to Dubin-Johnson syndrome –20°C Indefinite
o Defect in excretion of conjugated bilirubin
• Due to a reduction in the concentration or activity of intracellular binding protein, Other Liver Function Alterations During Disease
ligandin 1. Cirrhosis
• Does not show dark pigmented granules • Scar tissue replaces normal, healthy liver tissue
• Has normal gallbladder function o Causes blockage of blood flow to the liver
 • Common causes: • Total bilirubin (30 • PT
o Chronic alcoholism mg/dL) Associated condition:
o Chronic hepatitis B, C, D virus infections Decreased: • Ascitis
o Autoimmune hepatitis • Serum protein
o Inherited disorders Prolonged:
o Non-alcoholic steatohepatitis • PT
o Blocked bile ducts
o Drugs, toxins and infection AST – aspartate aminotransferase
ALT – alanine aminotransferase
2. Tumors GGT – gamma-glutamyl transferase
• Primary – begins in the liver ALP – alkaline phosphatase
• Metastatic – from other parts PT – prothrombin time
• Benign
o Hepatocellular adenoma – exclusive in females of child-bearing age • Tests to diagnose liver disease
o Hemangiomas – made up of a tangle of blood vessel, mesenchymal in nature a. Bilirubin
• Malignant b. ALT
o Hepatocellular carcinoma – due to a cohort effect related to infection with c. AST
hepatitis B & C viruses (most common) d. Albumin
o Hepatocarcinoma • Pharmacology
o Hepatoma a. Pharmacodynamics – what the drug does to the body
• Beneficial or harmful
3. Reye Syndrome b. Pharmacokinetics – what the body does to the drug
• Group of disorders by infectious, metabolic, toxic, or drug-related disease exclusive 1. Absorption
in children • Factors:
• Often preceded by a viral syndrome a. Lipid solubility: high/increased
• Characterized by: b. Polarity: non-polar
o Non-inflammatory encephalopathy c. pH: same as absorbing medium
o Fatty degeneration d. Water solubility: non-water soluble
o Mild hyperbilirubinemia 2. Distribution
o ↑ ammonia • Blood facilitates distribution
o ↑ aminotransferases (ALT, AST) 3. Metabolism
• Lessens toxicity of drugs
4. Drug & Alcohol Related Disorders • Liver – first pass effect
• Acetaminophen o Metabolizes drug to its inactive form
o Most common drug associated with serious hepatic injury • Phases:
o Can cause fatal hepatic necrosis a. Phase I
• Drugs that may cause liver injury 1. Oxidative – cytochrome P450
o Tranquilizers 2. Reduction
o Antibiotics 3. Hydrolysis
o Anti-neoplastic agents b. Phase II
o Lipid-lowering medications • Conjugative reaction – i.e. drug + glucuronic tranferase
o Anti-inflammatory 4. Excretion
Alcoholic Fatty Liver Alcoholic Hepatitis Alcoholic Cirrhosis • Kidney: major organ
Slight elevation: Moderately elevated: Increased: a. Glomerular filtration
• AST • AST • Liver function tests b. Proximal tubule – active secretion and reabsorption of H2O
• ALT • ALT Decreased: c. Distal tubule – passive transfer of lipid soluble drugs and
• GGT • GGT • Serum proteins reabsorption of H2O
• ALP Prolonged:
5. Hepatitis • Detection: nucleic acid hybridization or PCR technique
• Inflammation of liver tissue Natural infection Hepatitis B vaccine
• Symptoms (acute disease): • Anti-HBs • Anti-HBs
o Jaundice • Anti-HBc
o Dark urine
o Fatigue c. Hepatitis C
o Nausea • Non-A & non-B hepatitis
o Vomiting • RNA (Flaviviridae)
o Abdominal pain • Methods:
• Indication of chronic disease: prolonged elevation of serum transaminase level o Anti-HCV: enzyme immunoassay (EIA)
o HCV RNA: quantitative nucleic acid PCR assays
Hepatitis Nucleotide Incubation Period Primary MOT • Major causes of chronic hepatitis
A RNA 2-6 weeks Fecal-oral o Liver transplant
B DNA 8-26 weeks Parenteral, sexual o Asymptomatic
C RNA 2-15 weeks Parenteral, sexual o Mild elevation of liver function test
D RNA – Parenteral, sexual o Treated with pegylated interferon & ribavirin
E RNA 3-6 weeks Fecal-oral
o A & E – ingestion of contaminated food or water d. Hepatitis D
o B, C, D – can be perinatal • Requires HBsAg for replication
• Subvirus satellite virus infection
a. Hepatitis A • Defective RNA containing virus
• “Infectious hepatitis” / short incubation hepatitis • Coinfection / superinfection
• RNA virus (Picornavirus) • Treatment: interferon-α
• Self-limited symptoms, resolves within 3 weeks
• Detection: e. Hepatitis E
Serological antibody Assay Amplification • RNA (Hepeviridae)
IgM anti-HAV Presence of Ag Viral RNA by reverse • Short IP: 21-42 days
IgG anti-HAV Shed in feces transcriptase PCR • Detection: feces and bile (after 7 days of infection)
o Amplification: Nucleic acid detection techniques are more sensitive

b. Hepatitis B
• “Serum hepatits” / long incubation hepatitis
• DNA virus (Hepadnaviridae)
• Antigens:
1. HBcAg (Hepatitis B core antigen)
• Present in the nuclei of hepatocytes
• Anti-HBc develops earlier than surface antigen
• Serological marker: IgM antibodies to HBcAg
o IgM – specific to acute hepatitis B infection
2. HBsAg (Hepatitis B surface antigen)
• Australia antigen / hepatitis-associated antigen
• Present during the prodrome of acute hepatitis B
• Detected during the first 3-5 weeks
• Past infection: anti-HBs present
3. HBeAg
• Present in serum in either chronic or acute infections
• Presence of HBeAg in HBsAg carriers (chronic liver disease)
 Bilirubin Fractions Disorder Laboratory Result
Unconjugated bilirubin α-bilirubin Hepatocellular damage determination ALT > AST: acute hepatocellular damage
Conjugated bilirubin (diglucuronic bilirubin) β-bilirubin (monoconjugated) AST > ALT: chronic hepatocellular damage
γ-bilirubin (diconjugated) Obstructive jaundice ALP: ↑
Delta bilirubin δ-bilirubin 5’ nucleotidase: ↑
GGT: ↑
Total Bilirubin (Fractions) Alcoholic liver disease ALP: Normal
Unconjugated Conjugated Delta 5’ nucleotidase: Normal
• Reaction: • Reaction: • Reacts as conjugated GGT: ↑
+ diazo reagent + diazo reagent bilirubin
+ accelerator – accelerator • Covalently bound to Abnormal liver function test
• Bound to protein • Not bound to any albumin AST > 3 URL AST < 3 URL
protein • Seen in hepatic ALP < 2 URL ALP > 2 URL
obstruction Hepatocellular disease Cholestatic disease
Albumin: Normal Albumin: ↓ Albumin: Normal Albumin: ↓
Reference Ranges for Bilirubin in Adults and Infants Acute Chronic Acute cholestasis Chronic cholestasis
Population Type of Bilirubin Reference Range (mg/dL) hepatocellular hepatocellular Ultrasound / percutaneous cholangiography
Adults Conjugated 0.0-0.2 (0-3 µmol/L) disease disease Intrahepatic Extrahepatic
Unconjugated 0.2-0.8 (3-14 µmol/L) cholestasis cholestasis
Total 0.2-1.0 (3-17 µmol/L)
Premature infants Total at 24 hours 1-6 Isolated increased serum bilirubin
Total at 48 hours 6-8 Ruling out of hemolysis, subsequent fractionation of albumin
Total, 3-5 days 10-12 Conjugated Based on bilirubin concentration (mg/dL)
Full-term infants Total at 24 hours 2-6 With pigment Without pigment <3 > 25 5-20 ~5
Total at 48 hours 6-7 transiently
Total at 3-5 days 4-6
Dubin-Johnson Rotor Gilbert Crigler- Crigler- Lucey-
Najjar, Najjar, Driscoll
Diagnostic Strategies type 1 type 2
• Liver function test & integrity test
o Detection
o Diagnosis
o Evaluating severity
o Monitor therapy
o Assess the prognosis

Test Utility
Bilirubin Diagnose jaundice, modest correlation with severity
ALP Diagnose cholestasis & space occupying lesions
Bilirubin Diagnose disorders of metabolism & disorder of the newborn
Fractionation
AST Sensitive test of hepatocellular disease
AST>ALT: alcoholic disease, cirrhosis
ALT Sensitive and more specific test of hepatocellular disease
Albumin Indicator of chronicity and severity
PT Indicator of severity, early indicator of cirrhosis in chronic hepatitis