Professional Documents
Culture Documents
Pathologi Klinik Edited by Mememe
Pathologi Klinik Edited by Mememe
Pathologi Klinik Edited by Mememe
Gastrointestinal Block
Clinical Pathology
Bile Synthesis Produced by liver to used for emulsifying fats and binding them (micelles)
Carbohydrate Gluconeogenesis, Glycogenesis, Glycogenolysis
Metabolism
Detoxification Detoxification of toxins, drugs, alcohol, and the urea cycle.
Comverts ammonia to urea which excreted by kidney as urine
Hormone Metabolism Breakdown of insulin and steroid hormones
Lipid Metabolism Cholesterol Synthesis and Fat Storage
Coagulation Factors I (fibrinogen), II (prothrombin), V, VII, IX, X, XI as well as protein S and C
and anti thrombin (TEST PT)
Storage Glycogen, vit B12, Iron, Copper
Immunology RES system
Functions:
Indications:
AST in serum is less than ALT because only 20% in cytoplasm 80% in mitochondria
Mitochondrial enzymes ONLY appears if the cell membrane integrity is disrupted ONLY
happens if the cell undergoes NECROSIS or COMPLETE CELL DESTRUCTION
PATHOLOGI KLINIK EDITED BY MEMEME
If ALT and AST are found together in elevated amounts in the blood, liver damage is most
likely present
AST > ALT (complete cell destruction – karena AST banyak di nucleus)
AST = found in muscles and many other tissues besides the liver (NOT SPECIFIC)
ALT = almost exclusively found in the liver (SPECIFIC)
De Ritis Ratio: describe ratio between AST/ALT ( <1 for acute viral hepatitis where ALT was
usually higher than AST,>1 for alcoholic hepatitis where AST was higher than ALT)
2. Test for Cholestasis – Alkaline Phosphatase, 5NT (Nuleotidase) and GGT (Gamma Glutamyl
Transpeptidase)
ALP increases significantly for extra-hepatic blockage BUT only mildly increase in hepatocyte
destruction
ALP= MOST SENSITIVE FOR CHOLESTASIS BUT LESS SPECIFIC
(ALP elevation also seen in normal childhood, pregnancy and bone disease)
GGT = MOST SENSITIVE in finding biliary obstruction, cholangitis, or cholecystitis
If GGT > ALP = cholestasis
b. Protein Electrophoresis
(separate into fragment Alfa 1 glob, Alfa 2 glob, Beta glob, Gamma glob)
Protein profile useful as additional information to make differential diagnosis e.g Polyclonal
gammopathy
7. Etiology Testing
Auto Antibodies
AMA/Anti Mitochondrial Antibody Primary Biliary Cirrhosis
SMA/Smooth Muscle Antibody Chronic Active Hepatitis
ANA/Anti Nuclear Antibody Lupus, Lupoid type chronic active hepatitis
Acute Hepatitis A
Spread through contaminated food or water
PATHOLOGI KLINIK EDITED BY MEMEME
Ritis Ratio 0.4 (ALT>AST) due to rapid destruction on cytoplasmic enzyme more than
mitochondrial enzyme
AST ALT can reach hundreds and even thousands
Anti HAV IgM
Usually heals slowly with no complications
Acute Hepatitis B
Its virus contain several antigens such as
o HBsAG = surface
o HBcAG = core
o HBeAG = epsilon – marker for inefectivity
Ritis Ratio AST/ALT 0.6
AST ALT rises 5x normal
80-85% patient with infectious HBV will make antibody : Anti HBs, Anti HBc, Anti HBe
Anti HBc early appears in serum and remain positive for years in acute and chronic
hepatitis B even after resolution of infection
Last to appear HBs which becomes detectable after 6 months
Antibodies titer can a signifies immunity if anti HBs titer is > 100 IU/L
Chronic Hepatitis B
Present if HBsAG and HBV DNA remains detectable for more than 6 months
Classification according to histologial criteria : Chronic Active and Chronic Presistent
Hepatitis
Chronic Persistent : slight raise of AST ALT GGT (2-4x normal), de Ritis ratio < 1
Moderate Chronic Active : like chronic persistent, GGT and IG rises more
Highly Chronic Active : enzymes >10x normal, de Ritis Ratio >1, Bilirubin & GLDH up,
Albumin decrease
Anti HBs (+), anti HBc (+) = Previous Hep B
Anti HBc IGM, HBsAG (-) = Resolved Case
HBeAG (+) = High infectivity
HBeAG (-) = Clinically active
Chronic Hepatitis C
Often runs unremarkable or even silent – Very dangerous if become chronic 75-85% of
cases – Could risk for cirrhosis and hepatoma
Lab :
o Transaminase (AST/ALT) 10-15x from normal (if chronic may raised 3-5 fold)
o ALP and GGT higher than other viral hepatitis
PATHOLOGI KLINIK EDITED BY MEMEME
Hepatitis D
Hepatitis E
Notes:
Interferon Therapy
1. ALT and AST, Blood Count every 14 days in the first 2 months, then every 4-6 weeks
2. PCR for virus detection repeated every 3 to 6 months
3. TSH every three month because possibly thyroid dysfunction
Transferase increase
Protein synthesis reduced
AFP increase
If progression to liver cirrhosis GLDH increase
If carcinoma occur : GLDH and AFP will rise very high
PATHOLOGI KLINIK EDITED BY MEMEME
b. Hemochromatosis
Deposit of Fe in the liver
Transaminase, GGT, GLDH are midlly elevated, BSP and SI raised
c. Alpha-1-Antitrypsin Deficiency
non secretable variant of α 1 antitrypsin leads to accumulation this protein in hepatocytes
decreased serum alpha-1 antitrypsin
b. Inorganic Compounds
Poisoning by metals or metal salts to liver damage measurement the metal in urine serum
organ tissue or hair
PATHOLOGI KLINIK EDITED BY MEMEME
c. Medication (non specific lab pattern, mild liver damage) and Mushroom Poisoning
(varies clinical feature)
d. Others e.g cytomegalovirus, herpes simplex, various zoster, eb virus, adeno entervirus,
ebola virus
5. Miscellaneous
CMV, EBV, HSV, Adenovirus, Ebolavirus
6. Non-Alcoholic Fatty Liver Disease (NAFLD) and NASH (non alcohol steatohepatitis)
In overweight patients with hypercholesterolemia (hyperlipoproteinemia) and high IGT
ALT AST slight increase, de ritis ratio <1
GGT, ALP, ferritin, transferrin saturation slight increase
Diagnosis through histological exam
7. Liver Cirrhosis
Hypoalbuminemia, normal or slightly low AST, ALT, GGT, cholinesterase decrease,
ammonium concentration increase
AFP slight increase, continuous increase sugest liver cell ca development
8. HCC
Golden Standard: imaging and biopsy
- Supported by AFP > 500 µg/L + symptoms of the liver
- Extremely high AFP (AFP low sensitivity and low specificity)
- AFP used for monitoring therapy of HCC combined with USG
1. Acute Pancreatitis
Symptoms and Signs:
Severe pain radiating to the back Steatorrhea
Reduced bowel sounds Hemodynamic instability
Tachycardia and Tachypnea
Pathogenesis
Leakage of pancreatic enzymes to surrounding structures:
PATHOLOGI KLINIK EDITED BY MEMEME
Etiology
Most Common : gallstones and excessive alcohol intake, idiopathic
Others : hypertriglyceridemia, hypercalcemia, viral infection (mumps), trauma,
autoimmune, vasculitis, pregnancy and diabetes
Diagnosis – 2 out of 3 criteria
a. Abdominal Pain characteristic of acute pancreatitis
b. Serum amylase and lipase >3x normal value
Lipase > 2.5x Amylase = alcoholic liver disease
Serum lipase rises 4 to 8 hours from the onset of symptoms and normalizes within 7 to 14
days after treatment (LIPASE BETTER THAN AMYLASE FOR DIAGNOSIS)
c. Characteristic finding on CT scan
2. Chronic Pancreatitis
inflammation of the pancreas that is characterized by recurring or persistent abdominal pain
with or without steatorrhea or diabetes mellitus
Causes: Unknown (autoimmune, genetics, diseases e.g. cystic fibrosis, heavy alcohol use)
Symptoms
Upper abdominal pain that become worse with eating or drinking, and become constant and
disabling (+ vomiting and nausea, diarrhea, steatorrhea, weight loss even with regular eating)
Diagnosis
USG or CT or MRCP (blood tests are not helpful)
PATHOLOGI KLINIK EDITED BY MEMEME
3. Cholecystitis
Inflammation of the gallbladder
Causes
often caused by cholelithiasis that blocks the bile duct leads to thickening of bile and
cholestasis and secondary infection by GI tract organisms (particularly E. coli and Bacteroides)
inflammation of gallbladder extreme cases may lead to necrosis and rupture
Symptoms
Pain in the RUQ that may refer to the right scapula or right flank, low fever
Constant, Severe pain
Fever, jaundice, and shock indicates infection and abscess
Diagnosis
(+) Murphy Sign
Elevated ALP, Conjugated Bilirubin, WBC, Acute Phase Reactants
Elevated CRP
USG (sensitive and specific)
4. Ectopic Pregnancy
fertilized ovum is implanted in any tissue other than the uterine wall (most common: fallopian
tubes) A MEDICAL EMERGENCY
ACS recommends screening every 5 years >50 years old (along with sigmoidoscopy)
Methods:
1. Benzidine Base
2. Benidine Dihydrochloride
PATHOLOGI KLINIK EDITED BY MEMEME
3. Guaiac
4. Hematest
1,2,3 carcinogenic!
Principle (ColoScreen)
ColoScreen is a Guaiac Impregnated Paper enclosed in a cardboard frame oxidation of Guaiac produces
the color blue
2. Oxidation of Guaiac
O2 + Guaiac Oxidized Guaiac (Blue)
False Positive = sisa serat daging, produk mikroba usus (peroksidase), iron therapy
Pemeriksaan Tinja
Parameter Pemeriksaan:
1. Makroskopis
Warna Coklat-Coklat Tua = Normal
Kuning = Susu Jagung atau Unconjugated Bilirubin
Hijau = Sayur
Pucat = Tidak ada Urobilin
Merah Muda = perdarahan distal ATAU makan bit dan buah naga
Hitam = melena
Bau Normal karena indol, skatol, dan asam butirat
Konsistensi Agak lunak dan berbentuk
Diare = sangat lunak dan cair (Bristol 6 atau 7)
Konstipasi = keras (Bristol 1 atau 2)
Peragian Karbohidrat = lunak bercampur CO2
Lendir Inflamasi atau Rangsangan pada dinding usus
Parasit Cacing, telur cacing, kista protozoa, trofozoit, dsb
Darah Proximal = kehitaman
Distal = merah (bahkan bisa merah segar)
2. Mikroskopis
Purpose = finding undigested food contents, parasites and microbes, etc
PATHOLOGI KLINIK EDITED BY MEMEME
DD BLOOD IN STOOLS
Anal fissure
Colorectal cancer
Crohns disease
Ulcerative colitis
Internal hemorrhoids
Inflammatory enteritis – inflammation of small intestine can be caused by :
o E.coli enteritis ETEC (Traveller’s diarrhea)
o Campylobacter enteritis
o Shigellosis
o Salmonellosis
o Gastroenteritis (dysentery)
o Staphylococcus aureus
o Radiation enteritis
Diverticulosis
Upper GI bleeding
Peptic ulcer disease
Esophageal varices
Gastric Cancer
Constipation