Liver Function Tests Synthetic Function Excretory Function Hepatocellular

Liver Function Tests • Synthetic Function • Excretory Function • Hepatocellular Necrosis • Cholestasis • Others

Liver Function Tests Liver Battery Others • • Prothrombin Time (PT) Total Cholesterol Total Protein Albumin Total bilirubin GOT (AST) GPT (ALT) Alkaline Phosphatase (ALP) • Direct Bilirubin Urine Bilirubin Urobilinogen • g-GTP

Components of Liver Function Tests Synthetic function Cholesterol Albumin Prothrombin Time Hepatocellular Necrosis AST ALT Liver Function Excretory Function Total / Direct Bilirubin Urine Urobilinogen Cholestasis ALP g-GTP Serum Bilirubin

Bilirubin ; 간 excretory function을 반영 • 적혈구 헤모글로빈의 분해 산물 bilirubin conjugation enterohepatic circulation urobilinogen

Hyperbilirubinemia Unconjugated Conjugated (total bilirubin의 80% 이상) (total bilirubin의 50% 이상) 1. 과형성 - hemolysis 1. 간실질 장애 - 급, 만성 간염, 간경변 2. 운반장애 - heart failure - portosystemic shunt 2. 간외 담즙정체 - 담석, 췌장염 - 악성종양(담도암, 췌장암) - 간흡충증, 회충 3. Conjugation 장애 - Gilbert 증후군 - Crigler-Najjar I, II 3. 선천성 간 배설장애 - Dubin-Johnson 증후군

Normal Bilirubin Metabolism Gilbert Syndrome Increased Bilirubin production Biliary obstruction

Gilbert Syndrome 1. Chronic indirect hyperbilirubinemia의 가장 흔한 원인( 약 68%) 2. 전체 인구의 3~10%에서 발견됨 3. 간세포에서 bilirubin이 glucuronide conjugation되는 과 정에 관여하는 효소(bilirubin-UGT)의 부분적 결핍이 원 인 4. 혈청 total bilirubin; 1. 2 ~ 3 mg/d. L (< 7 mg/d. L) 5. 진단; 1) 만성적으로 경미한 indirect hyperbilirubinemia 2) 간질환의 징후가 없고, 다른 간기능검사는 정 상 3) hemolysis가 배제된 경우(Hb, reticulocyte…)

간 질환의 범주에 따른 LFT 이상소견 검사 Hepatocellular Cholestatic Infiltrative ALT +++ ALP +++ - ~ +++ -~+ Bilirubin PT 정상 ~ 연장 Vit K에 반응(-) Vit K에 반응(+) 정상

31/M, RUQ discomfort, since 2 wks ago Protein Alumin T-Bilirubin D-Bilirubin AST ALP GGT 7. 0 g/d. L 4. 2 mg/d. L 2. 2 mg/d. L 1823 IU/L 1754 IU/L 139 IU/L 298 IU/L PT: 78 % Urine: BIL(+++), UB (+++) 1. Conjugated hyperbilirubinemia 2. Marked elevation of AST/ALT 3. Mild elevation of ALP 4. Normal albumin 5. Mild prolongation of PT Assessment ?

31/M, RUQ discomfort, since 2 wks ago Protein Alumin T-Bilirubin D-Bilirubin AST ALP GGT 7. 0 g/d. L 4. 2 mg/d. L 2. 2 mg/d. L 1823 IU/L 1754 IU/L 139 IU/L 298 IU/L PT: 78 % Urine: BIL(+++), UB (+++) 1. Conjugated hyperbilirubinemia 2. Marked elevation of AST/ALT 3. Mild elevation of ALP 4. Normal albumin 5. Mild prolongation of PT Acute Hepatitis !

Suspected Acute Hepatitis Hx; drug, alcohol P/E; chronic ? , tender hepatomegaly anti-HAV(Ig. M) HBs. Ag, anti-HBc(Ig. M) anti-HCV, HCV-PCR + + Acute hepatitis A Acute hepatitis B + Acute hepatitis C Consider acute hepatitis E, Wilson’s dis (< age 40) autoimmune heptitis (female), EBV or CMV infection

39/M, LFT abnormality for 10 yrs No Sx, 182 cm/115 Kg T-Cholest. Protein Alumin T-Bilirubin AST ALP GGT PT: 225 7. 8 4. 5 1. 3 100 117 75 45 mg/d. L mg/d. L IU/L 105 % 1. Mild elevation of AST, ALT, GGT 2. Normal synthetic and excretary function Assessment ?

39/M, LFT abnormality for 10 yrs No Sx, 182 cm/115 Kg T-Cholest. Protein Alumin T-Bilirubin AST ALP GGT PT: 225 7. 8 4. 5 1. 3 100 117 75 45 mg/d. L mg/d. L IU/L 105 % 1. Mild elevation of AST, ALT, GGT 2. Normal synthetic and excretary function Chronic Hepatitis !

Suspected Chronic Hepatitis Hx; drug, alcohol, fam. Hx P/E; chronic ? HBs. Ag anti-HCV Ceruloplasmin (age < 40) ANA, ASMA (female) Obese ? DM(+) ? Hyperlipidemia ? + + < 20 + + Chr hepatitis B Chr hepatitis C w/u for Wilson’s dis. w/u for autoimm. hep. USG, wt reduction, DM Tx consider liver Bx.

39/M, LFT abnormality for 10 yrs No Sx, 182 cm/115 Kg, BMI= 35. 6 ; Non-Alcoholic Steato. Hepatitis (NASH)

16/M, LFT abnormality No Sx T-Cholest. Protein Alumin T-Bilirubin AST ALP GGT PT: 173 7. 6 4. 5 1. 2 29 34 189 33 mg/d. L mg/d. L IU/L 97 % 1. Mild elevation of ALP Assessment ?

18/M, LFT abnormality No Sx T-Cholest. Protein Alumin T-Bilirubin AST ALP GGT PT: 173 7. 6 4. 5 1. 2 29 34 189 33 mg/d. L mg/d. L IU/L 97 % 1. Mild elevation of ALP Normal Adolescence !

61/F, RUQ Discomfort (4 wks ago) dark urine and itching (1 wk ago) T-Cholest. Protein Alumin T-Bilirubin D-Bilirubin AST ALP GGT 155 mg/d. L 6. 4 g/d. L 3. 2 g/d. L 14. 5 mg/d. L 9. 5 mg/d. L 84 IU/L 108 IU/L 825 IU/L 246 IU/L PT: Urine: Stool: 87 % BIL(++), UB (-) Gray color 1. Conjugated hyperbilirubinemia 2. Marked Increase of ALP/GGT 3. Bilirubin without UB in urine 4. Gray colored stool 5. Moderate increase of AST/ALT 6. Preserved Synthetic Function Assessment ?

61/F, RUQ Discomfort (4 wks ago) dark urine and itching (1 wk ago) T-Cholest. Protein Alumin T-Bilirubin D-Bilirubin AST ALP GGT 155 mg/d. L 6. 4 g/d. L 3. 2 g/d. L 14. 5 mg/d. L 9. 5 mg/d. L 84 IU/L 108 IU/L 825 IU/L 246 IU/L PT: Urine: Stool: 87 % BIL(++), UB (-) Gray color 1. Marked Increase of ALP/GGT 2. Conjugated hyperbilirubinemia 3. Bilirubin without UB in urine 4. Gray colored stool 5. Moderate increase of AST/ALT 6. Preserved Synthetic Function Obstructive Jaundice !

Bilirubin ; 간 excretory function을 반영 bilirubin conjugation enterohepatic circulation urobilinogen

Obstructive Jaundice Hx; pruritus, stool color, abd. pain, drug USG / CT BD dilation Nl anti-mt ab. + PBC Liver Bx - Cholangiography

61/F, RUQ Discomfort (4 wks ago) red urine and itching (1 wk ago) Pancreatic Head Cancer

54/F, LFT abnormality No Sx T-Cholest. Protein Alumin T-Bilirubin AST ALP GGT PT: 218 8. 1 3. 9 0. 5 64 29 362 322 mg/d. L mg/d. L IU/L 101 % 1. Marked elevation of ALP, GGT 2. Mild elevation of AST Assessment ?

54/F, LFT abnormality No Sx T-Cholest. Protein Alumin T-Bilirubin AST ALP GGT 218 8. 1 3. 9 0. 5 64 29 362 322 mg/d. L mg/d. L IU/L PT: 101 % 1. Marked elevation of ALP, GGT 2. Mild elevation of AST Cholestatic dis. vs. Infiltrative dis.

Elevated ALP Hx; pruritus, abd. pain, bone Sx, preg? , drug GGT Nl Extrahepatic source E Stone, Focal lesion Biliary tr. abnl. USG (-) anti-mt. Ab. AFP + E PBC !, liver Bx r/o HCC

43/F, abdominal distension, since 2 wks ago T-Cholest. Protein Alumin T-Bilirubin AST ALP GGT 121 5. 8 2. 8 1. 2 174 41 113 378 mg/d. L mg/d. L IU/L PT: 69 % 1. 2. 3. 4. 5. Mild elevation of AST, ALT AST / ALT > 4 Marked elevation of GGT Normal ALP Mild prolongation of PT Assessment ?

43/F, abdominal distension, since 2 wks ago T-Cholest. Protein Alumin T-Bilirubin AST ALP GGT 121 5. 8 2. 8 1. 2 174 41 113 378 mg/d. L mg/d. L IU/L PT: 69 % 1. 2. 3. 4. 5. Mild elevation of AST, ALT AST / ALT > 4 Marked elevation of GGT Normal ALP Mild prolongation of PT Alcoholic Cirrhosis !

Cirrhosis (Alcoholic)

20/M, Hyperbilirubinemia since 2 yrs ago No Sx T-Cholest. Protein Alumin T-Bilirubin D-Bilirubin AST ALP GGT 168 7. 4 4. 0 2. 7 0. 5 29 35 47 47 mg/d. L mg/d. L IU/L Hb: 14. 4 g/d. L 1. Mild elevation of total bilirubin 2. D- / T- bilirubin; 18. 5 % Assessment ?

20/M, Hyperbilirubinemia since 2 yrs ago No Sx T-Cholest. Protein Alumin T-Bilirubin D-Bilirubin AST ALP GGT 168 7. 4 4. 0 2. 7 0. 5 29 35 47 47 mg/d. L mg/d. L IU/L Hb: 14. 4 g/d. L 1. Mild elevation of total bilirubin 2. D- / T- bilirubin; 18. 5 % Gilbert syndrome !

Isolated Elevation of Bilirubin Hx; drug, fam Hx d-bilirubin Unconjugated ! Hb, reticulocyte # Nl Gilbert synd. Abnl. w/u for hemolysis Conjugated ! USG Nl Abnl. Dubin-Johnson or Rotor Synd (Liver Bx) Obst. or parenchymal liver dis.

48/M, HBs. Ag(+), No Sx T-Cholest. Protein Alumin T-Bilirubin AST ALP GGT 151 7. 6 4. 5 0. 8 29 25 87 26 mg/d. L mg/d. L IU/L PT: 98 % AFP 1. 7 ng/m. L Completely normal LFT Assessment ?

48/M, HBs. Ag(+), No Sx Completely Normal LFT, AFP Arterial Phase Portal Phase Hepatic Angiography