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INVESTIGATIONS OF. LIVER DISORDERS. BLOOD EXAMINATION. 2. CHEST X- RAY. 3. LIVER FUNCTION TESTS. 4. IMAGING STUDIES. Non invasive Invasive. 5. LIVER BIOPSY. Blood Examination. Routine examinations Infections C/c liver disease Tumor markers. Viral hepatitis.
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INVESTIGATIONS OF LIVER DISORDERS
BLOOD EXAMINATION 2. CHEST X- RAY 3. LIVER FUNCTION TESTS 4. IMAGING STUDIES • Non invasive • Invasive 5. LIVER BIOPSY
Blood Examination • Routine examinations Infections C/c liver disease • Tumor markers
Viral hepatitis • Hepatitis A - IgM Anti. HAV antibodies • Hepatitis B – HBs Ag – ‘Australia antigen’ HBe Ag – for replication &infectivity Anti HBS – immunity to HBV • Hepatitis C – Anti.HCV antibody • Hepatitis D – PCR HDV – RNA • Hepatitis E – Anti HEV anti bodies
Tumor Markers Alfa - feto protein In Hepatocellular carcinoma Above 500ng/dl Also in Germ cell tumors Secondaries Cirrhosis Des-y-carboxy prothrombin Glypican-3
CHEST X-RAY • Canon ball secondaries’. • Pleural effusion.
Liver Function Tests Tests based on the excretory function Tests based on the metabolic capacity of the liver Tests based on synthetic function of liver Tests based on serum enzymes
SERUM BILIRUBIN Normal value Total - 0.2- 0.8 mg/dl Unconjugated bilirubin - 0.2 – 0.6 mg /dl Conjugated bilirubin - 0 – 0.2 mg / dl
Estimation • Vanden Bergh reaction Diazotized sulfanilic acid + bilirubin azobilirubin (purple) Absorbs light of 540nm
Conjugated / Direct bilirubin - Reacts immediately on mixing with reagent i.e., within 1 min. Elevated in obstructive & hepatocellular jaundise • Unconjugated / Indirect bilirubin • Reacts on addition of alcohol; reacts within 30 min. Elevated in haemolytic jaundice Biphasic reaction
Bilirubin – Fouchet’s test Fouchet’s reagent – FeCl3 in trichloroacetic acid. Urobilinogen – Ehrlich test Ehrlich’s reagent – paradimethyl amino benzaldehyde in hydrochloric acid. Bile salts – Hay’s test Urine Analysis
Obstructive jaundice Bilirubin - + ve Bile salts - + ve Uroblinogen - - ve • Pre hepatic jaundice Urobilinogen - +ve Bile salts - -ve Bilirubin - -ve
Dye excretion • Dyes used - Indocyanin green - Sulfobromophthlein • Done for - hepatic blood flow - portal blood flow - Porto systemic shunt - surgical shunt evaluation
Tests for metabolic capacity • Amino pyrine breath test – using C 14 labeled aminopyrine. Aminopyrine De methylation 14CO2 liver • Normal people expires – 6.6 % +/- 1.3 % • in 2 hrs. Uses - assess residual functional liver cells. - prognosis of a disease.
Galactose tolerance testPlasma Amino AcidsLidocain clearance testMetabolite tested is Monoethylglycinexlide
Tests To Assess Synthetic Function • Serum albumin normal 35 -50 gm /dl albumin decreased; A/G ratio reversal • Prothrombin time normal 12 -16 sec. • Clotting factors - 1,2, 5, 7, 9, 10, 12, 13 are synthesized by liver. • Vitamin K dependent clotting factors – 2, 7, 9, 10.
AMINOTRANSFERASES • Alanine amino transferase (ALT/SGPT) • Aspartate Aminotransferase (AST/SGOT) Normal value : 5 – 40 IU/L Elevated in - hepatitis - cirrhosis - malignancy of liver AST/ALT ratio
Markers of obstructive liver diseases • Alkaline phosphatase (ALP) • Seen in the lining epithelium of biliary tract. Normal value – 30-130 IU / L Elevated in • Liver disorders : Biliary obstruction or liver infilteration • Bone disorders • Normal in children Regans isoenzyme
Gamma glutamyl transferase To confirm the organ specificity of ALP Normal value –10 – 48 iu /L Elevated in - c/c alcoholism - Biliary obstruction 5’ Nucleotidase Normal: 0-11 iu/l
Immunological markers • Antinuclear antibodies • Antimitochondrial antibodies • LKM antibodies • Liver membrane antibodies
INDICATIONS FOR LIVER BIOPSY • Determine the cause of abnormal hepatic biochemical tests. • Diagnosis of multi system infiltrative, inflammatory or granulomatous diseases. • Diagnosis of neoplasms. • Grading and staging of c/c hepatitis. • Evaluation of cholestatic & alcoholic liver disease. • Evaluate the status of liver following transplantation; evaluate donor liver prior to harvesting.
TYPES • Trans cutaneous • Ultra sound or CT guided • Laparoscopic • Trans jugular approach
Per Cutaneous Liver Biopsy Procedure In the space b/w ant. Axillary line & mid axillary line b/w 6-9 ribs.
Menghini needle Vilm –Silverman needle Using Suction technique needlesCutting technique needles Ex. Menghini needle Vilm – silverman needle Klatskin needle Tru – cut needle jamshidi needle
Contraindications • Absolute . Bleeding disorder • Hydatid cysts • Haemangioma / vascular tumors • Uncooperative patient • Unavailability of blood transfusion support • Relative • Ascites • Infections of right pleural cavity • Infections below diaphragm
Complications • Pain • Hemorrhage • Intra hepatic • Intra peritoneal • Hemobilia • Bile peritonitis • Bacteremia • Sepsis & abscess • A-V fistula • Injury to other organs
Trans Jugular Liver Biopsy Indications • Significant coagulopathy • Moderate to severe ascites • Fulminant hepatic failure • Failed per cutaneous attempt
PROCEDURE Obtaining liver tissue from within the vascular system. Through percutaneous puncture of right Int. Jugular vein. Passage of a catheter into right hepatic vein Biopsy of liver using a special needle Under fluoroscopic guidance.
COMPLICATIONS • Neck hematoma • Transient Horner’s syndrome. • Transient dysphonia • Cardiac arrhythmia. • Perforation of liver capsule.
Laparoscopic liver biopsy • Indications • Diagnosis of peritoneal metastasis • Chronic liver disease • Staging of malignancies • non conclusive imaging studies • Contraindications • Severe cardiopulmonary failure • A/C M.I • Intestinal obstructions • Bacterial peritonitis
COMPLICATIONS • MAJOR • Abdominal viscus perforation • Bleeding from liver biopsy site • Hemobilia • Spleen lacerations • MINOR • Ascitic fluid leakage • Abdominal wall hematoma • Post laparoscopic fever
NON INVASIVE IMAGING OF LIVER • X ray • Ultrasonography • Hepatic Doppler sonography • CT /MRI • MRCP
X RAY Hepatobiliary calcifications Portal venous gas shadow Abscess Pneumobilia Porcelain gall bladder
Porcelian gallbladder pneumobilia
Ultrasonography • Most commonly used imaging modality for liver pathologies. • Best evaluated with a 3 – 5 MHz transducer.