Nutrition 445

Case Study 3
Due April 20, 2015
Case:
A 36-year old man was admitted to a hospital following episodes of nausea, vomiting,
and general malaise. His urine was darker than usual. Upon examination it was
discovered that his liver was enlarged and tender to palpation. Liver function tests were
abnormal; plasma ALT was 1500 IU/L; AST was 400 IU/L. During the next 24 hours the
man developed jaundice, and his plasma total bilirubin was 9.0 mg/dL (154 mmol/L). A
diagnosis of hepatitis was made.
Questions:
1) Define hepatitis and discuss the major causes of hepatitis.
a. Hepatitis is a highly contagious liver infection caused by a form of the
hepatitis virus. A person can contact the virus from contaminated food or
water or by coming in contact with someone who is infected or their
bodily fluids.
2) What reactions are catalyzed by AST and ALT? and what coenzyme is required?
a. AST catalyzes the transamination between amino acids aspartate and
glutamate and ketoacids oxaloacetate and a-ketoglutarate.
b. ALT catalyzes the transamination between amino acids alanine and
glutamate and ketoacids pyruvate and a-ketoglutarate.
c. Transaminations requires pyridoxal phosphate, a form of vitamin B6, as a
coenzyme.
3) What conditions are important to maintain in performing the enzyme assays?
a. Certain foods and medications could affect the results of a liver function
test. Fasting and stopping medication may be appropriate. To perform an
accurate test salt, pH, and temperature levels have to be accurate or the
calculations could be off. The rate of the reaction, active site, binding
region, and substrate level have to be unaffected.
4) Which other enzymes might have been elevated in the plasma?
a. Alkaline phosphate, an enzyme in the cells lining the biliary duct, could be
elevated. Levels will rise during an obstruction or liver disease.
b. Gamma-glutamyl transpeptidase, an enzyme in the blood, is sensitive to
alkaline phosphate, alanine aminotransferase, and aspartate transferase
levels. Elevated levels of GGT are seen in any type of liver disease, with
modest elevations if hepatitis occurs.
c. Lactate dehydrogenase is an enzyme found in the liver. Abnormal levels
indicate tissue damage, disease, or injury.
d. 5 nucleotidase is an enzyme produced in the liver. Testing levels in the
blood can be used to tell if there is liver or skeletal muscle damage.
5) How does total bilirubin relate to direct and indirect bilirubin?
a. Direct bilirubin measures the bilirubin after it combines with albumin in
the liver the become water soluble

b. Indirect bilirubin, a product of heme, is the fat-soluble version made

before coming in contact with albumin. Abnormal levels are an indication
of disease.
c. Total bilirubin and direct bilirubin are measured, and then subtracted to
obtain indirect bilirubin levels.
6) What other diagnostic tests need to be done for this patient before a treatment plan
can be recommended?
a. Testing alkaline phosphate levels is part of a routine liver functioning test.
Higher amounts indicate liver or bone disease.
b. Testing albumin levels in the plasma is used during a liver panel test.
Albumin levels will drop if the liver is damaged. A liver panel test also
tests enzyme and bilirubin levels.
c. Doctors can perform ultrasounds, CAT scans, or MRIs to take a picture of
the liver to see if its swollen.
References:
Alter, HJ: Hepatitis. Semin Liver Dis. 6:1, 1986.
Cassidy, WM, Reynolds, TB: Serum lactate dehydrogenase in the differential diagnosis of
acute hepatocellular injury. J Clin Gastroenterol. 19(2); 118, 1994.
Jacobson, IM, Dienstag, JL.: The delta hepatitis agent: viral hepatitis, type D.
Gastroenterology. 86: 1614, 1985.