By: Prof. dr. Suwandhi Widjaja, Sp.PD, Ph.D
Patients often demonstrate to physicians who noted the results of laboratory liver function disturbance, then asked for an explanation of the results of laboratory medicine and even begged on the liver function disturbances.
As a clinical doctor we must not forget that the question was actually referring to people with my disease diagnosis was what exactly! To be able to answer questions with accurate, we must know how the medical history, symptomatology, and history relevant to the clinical condition. History taking medicines, including traditional medicine, an exposition with chemicals / food is also worth noting. Physical Permeriksaan to search for signs of chronic liver disease such as palmar erithema, jaundice, spider Nevi dansebagainya very helpful in analyzing the results of this laboratory. It must be remembered that liver function abnormalities, can also be found in other diseases beyond heart disease, such as thyroid disease, heart trouble and kidney trouble. Therefore, we need another investigation in order to provide conclusions from the results of this laboratory.
Heart of the actual physiology.
Liver is the largest solid organ situated in the upper right abdomen. This organ has an important role because it is the regulator of all the metabolism of carbohydrates, proteins and fats. Place the synthesis of various protein components, blood clotting, cholesterol, urea and other substances vital. In addition, also the site of formation and distribution of bile acids and toxins detox center and destruction (degradation) of steroid hormones such as estrogen.
In liver tissue, there Kupfer cells, which is very important in the elimination of foreign organisms both bacteria and viruses. Therefore, to show the disruption of liver function, there was one row of a test that is usually made to assess the heart function. Keep in mind that all medical tests have different sensitivity and specificity, then the interpretation of test results is influenced by such things.
Liver function tests
Because the liver function in the body has a multifunction then hatipun diverse physiological tests in accordance with what we want value.
For functions such as protein synthesis, blood clots and fatty substances are usually checked for albumin, the protrombin and cholesterol. The function of excretion / transport, checked bilirubin, alkaline phosphatase. ∂-GT. Damage to liver cells or liver tissue, examined SGOT (AST), SGPT (ALT). The presence of young growth of liver cells (liver cell carcinomas), alpha-Feto Protein. Contact with hepatitis B virus, namely: HBsAg, AntiHBs, HBeAg, anti HBe, anti-HBc, HBVDNA, and hepatitis C virus, namely: anti-HCV, HCV RNA, HCV genotype.
In general there are two types of heart function disorders.
1. General or specific inflammation in the liver inflammation that causes tissue damage or liver cells.
2. Presence of bile duct obstruction.
Various kinds of liver function test results are disrupted.
Liver function tests that occur in bacterial and viral infections are not systemic viral hepatitis. Such patients, usually marked by high fever, myalgia, nausea, asthenia, and so forth. Liver function seen here would be the increase in SGOT, SGPT and ∂-GT between 3-5X normal value. Albumin can be slightly decreased when the infections had occurred a long time and bilirubin may increase slightly, especially if the infection is severe. (See table 1)
Liver function tests in acute viral hepatitis or drug induce hepatitis. Bilirubin liver function such as direct / indirect can be increased is usually less than 10 mg%, except at kolestatik hepatitis, bilirubin can be more than 10 mg%. SGOT, SGPT increased by more than 5 to 20 times the normal value. ∂-GT and alkalifosfatase increased two to four times the normal value, except to hepatitis kolestatik could be higher. Albumin / globulin was usually normal except in case of fulminant hepatitis, the albumin globulin ratio can be reversed and the protrombin can elongate (see Table 2)
Liver function tests in bile duct obstruction. Bilirubin direct / indirect can be very high (> 20 mg%), especially when the obstruction is long enough. Increased SGOT and SGPT are usually not very high, about less than four times the normal value. ∂-GT and alkalifosfatase be increased once more than five times the normal value. Cholesterol was also increased (see table 3).
Liver function tests in the fatty liver (fatty liver). Albumin / globulin and bilirubin are usually still normal. SGOT and SGPT increased approximately two to three times the normal value as well as ∂-GT and alkalifosfatase increased by about ½ to 1 times the normal value. Triglyserida and cholesterol levels were also seen rising. These disorders are often in women with young age / mid, fat, and usually no complaints or complain of feeling uncomfortable at the upper right abdomen. In the case of fatty liver is the primary then all signs of hepatitis C should be negative. (See table 4)
The existence of signs of hepatitis virus in the patient's blood.
Patients with acute or recent hepatitis A recover from hepatitis A, marked by a positive IgM anti-HAV. Anti-HAV IgG positive was frequently found in children or adults from developing countries with poor environmental sanitation. This may indicate patients infected with hepatitis A virus been in the past. Therefore, the prevalence of HAV IgG can be used as an index of a country's environmental sanitation.
Recover from Hepatitis B infection, characterized by the disappearance of HBsAg and the emergence of anti-HBs. Anti-HBc IgM was heading, it means a new (recent) infected with hepatitis B.
Chronic hepatitis B.
1. Phase of chronic hepatitis replikatip / tolerant. Marked with HBsAg +, HBeAg +, HBVDNA + (quantitative able> 105 copies / ml). But his heart function to normal.
2. Reactive chronic active hepatitis (Necro-inflamatory stage). Marked with HBsAg +, HBeAg +, HBVDNA + (quantitative able> 105 copies / ml). But his heart Abnormal haematological, especially SGOT / PT level (> 3X the normal value), albumin / globulin usually still normal, bilirubin can menigkat few (<than 3 mg%)
3. Chronic hepatitis B mutants. Here HBsAg +, HBeAg negative, but anti-HBe +, and HBV DNA +. Disturbed liver function. Usually people with this, have a more severe liver disease.
4. Inactivated hepatitis / integrative. HBsAg +, anti-HBe +, HBV DNA negative or below <103 copies / ml and normal heart function.
5. B liver cirrhosis, the ratio of albumin / globulin upside down, bilirubin increased (<than 5 mg%), AST> ALT, usually increased by approximately 2 to 4 times normal, but severe cirrhosis of the AST / ALT can be normal. HBsAg +, HBeAg / anti-HBe can be positive. Frequency of HBV-DNA was negative.
Hepatitis C
1. Recovered from hepatitis C, characterized by anti-HCV +, HCV-RNA - (negative), normal liver function.
2. Chronic hepatitis C, marked with Anti HCV +, HCV-RNA +, most disturbed liver function, but can be normal in a small portion of the patient.
3. C liver cirrhosis, the ratio of albumin / globulin upside down, bilirubin increased (<than 5mg%), AST> ALT, usually increased by approximately 2 to 4 times normal, but severe cirrhosis of the AST / ALT may be normal. Anti-HCV and HCV-RNA positive.
Genotype of hepatitis.
In the eight genotypes of hepatitis B exist and are named alphabetically A through H. In Indonesia, mainly genotypes B and C. There are six genotypes of hepatitis C and was named the number 1 through 6. In one genotype are further divided into additional sub-genotypes and lowercase letters from a through c. In Indonesia it was found that genotype 1b. (> 65%)
Liver function abnormalities are not specific
This usually occurs in patients with liver disease that has affected the functions of other organs such as kidney, lung, heart, etc.. In such cases, clinical features and investigation such as ultrasound, CT scan and ERCP (endoscopy retrograde Cholangio Pancreatography) or even liver biopsy is usually necessary to enforce his diagnosis.
Results of laboratory normal liver function in patients with chronic liver disease.
Patients with chronic hepatitis B in the replicative phase, an inactive / integrative often show abnormal laboratory results. Also in patients with hepatitis C (with HCV-RNA +), also showed normal liver function tests. In patients with liver cirrhosis kompensata also often have normal liver function tests. In advanced liver cirrhosis often we get the level of ALT / AST normal, this happens because the number of liver cells in cirrhosis was much less severe so that relatively little damage to liver cells. But it will be seen rising bilirubin levels and the ratio of albumin / globulin will be reversed. When we examine more closely the levels will be higher SGOT SGPT.
Reporting the results of hepatitis virus marker for quantitatively and qualitatively.
1. Hepatitis B.
Qualitative examination was always more sensitive than the quantitative examination. How to quantitative examination of hepatitis B treated with a variety of ways and each way has a certain sensitivity and also can use the reporting of certain units. See table 5. Quantitative results of hepatitis B above 105 copies / ml is considered the limit for treatment.
2. Hepatitis C.
Also a qualitative examination is more sensitive than quantitative. There are various methods of examination kuantiatif HCV and have different sensitivity ranges. The quantitative results from a quantitative examination of how HCV can not be equated with the inspection results of HCV in a different way. Table 6
The disease is rare but liver function disturbances showed
• Thyroid disease / goiter gland.
• auto-immune liver disease (AIH)
• Wilson disease
• Alpha-1-deficiency antitrypsisn
• Celiac disease
• Muscle disorders
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Very informative!!!
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