Liver Function Tests

Functions of liver Excretory Function:Bilepigments, bile salts and other organic anions like BSP (Bromosulphthalein), Indocyanine green (ICG), Urobilinogen Metabolic Functions

Test based on this function Van den Bergh Test Fouchets test Ehrlich test BSP Excretion Test 1. 2. 3. Galactose tolerance test Rate of Urea synthesis Plasma amino acid levels

Synthetic function

Serum total protein level Serum albumin level Prothrombin time . Hippuric acid test 1.Transaminases 2.Alkaline Phosphatase 3.gamma glutamyl transpeptidase 4.51 Nucleotidase 5.Leucineamino peptidase

Detoxification Serum enzymes

Tests based on Excretory Function

1.Serum Bilirubin level: Bilirubin is an endogenous anion derived from hemoglobin degradation from the RBC. The classification of bilirubin into direct and indirect bilirubin are based on the original van der Bergh method of measuring bilirubin. Bilirubin is altered by exposure to light so serum and plasma samples must be kept in dark before measurements are made. Direct Van den bergh test Conjugated bilirubin + Diazotised sulphanilic acid purple coloured complex (azobilirubin). The intensity of which is measured Colorimetrically at 450 nm. Conjugated bilirubin is also called direct bilirubin or water soluble bilirubin. Indirect Van den bergh test Unconjugated bilirubin + Diazotised sulphanilic acid+ Methanol purple coloured complex (azobilirubin). The intensity of which is measured Colorimetrically at 450 nm. This estimates total Bilirubin levels (Conjugated+ Unconjugated bilirubin). Indirect Bilirubin == Total bilirubin Direct bilirubin

Type of bilirubin

Normal ranges

Increased in type of jaundice

Conjugated bilirubin

0 to 0.2 mg/dl

Obstructive jaundice or regurgitation jaundice or Post hepatic Jaundice Prehepatic or hemolytic Jaundice

Unconjugated bilirubin

0.2 to 1 mg/dl

Both Conjugated bilirubin and Unconjugated bilirubin

0.2 to 1 mg/dl

Hepatic or Hepatocellular jaundice

2. Bilirubin in Urine: This is detected by

Fouchets test:
Test Observation Inference

10 ml of urine + few Bilirubin and biliverdin crystals of magnesium gets oxidized to blue or sulphate.heat with green compounds barium chloride solution A white ppt. of barium sulphate is formed to which bilirubin adheres if present.This is collected on to a filter paper and Fouchets reagent is added (Ferric Chloride In Trichloro acetic acid)

Bilirubin is present in urine.This is seen in obstructive jaundice. and in hepatocellular jaundice.

3.Test for Urobilinogen :

Ehrlichs Test:
Test Observation a. 10 ml of urine + 1 ml of Ehrlich reagent (dimethyl amino benzaldehyd e) Inference Type of Jaundice 1.Hemolytic

Pink colour 1.Increased UBG which persists even after 10 times dilution 2. Decreased UBG

b. Pink Colour not seen

2. Obstructive

4. Bile salts in urine : This is seen in Obstructive Jaundice. This is detected By Hays Test.
Test Observation Inference

Sprinkle some Sulphur 1. Sulphur powder powder to 5 ml of floats at the top urine in a test 2.sulphur powder tube sinks to the bottom

1.Bile salts absent 2.Bile salts Present (Obstructive Jaundice)

5. Bromosulphthalein test:
A single dose of BSP (50 g/l) is given and the serum concentration is measured at 45 minutes and at 2 hours. In normal people after 45 minutes less than 5% is retained. Any Increase in retention time indicates Hepatocellular impairment.

Tests to assess the metabolic capacity of the liver

Galactose tolerance test: Liver is the only organ that helps in the metabolism of Galactose that is in its conversion to glucose, the rate limiting step is catalysed by Galactose 1 phosphate uridyl transferase.. 350 mg of glucose /kg body weight is given as 25 to 30 % solution intravenously within 3 minutes.. Galactose level in blood is measured at 10 minute intervals for 1 hour. In normal people the half life of Galactose in blood is about 10 to 15 minutes., whereas in patients with cirrhosis and infective hepatitis it is markedly longer. Plasma amino acids: The amino acid profile is abnormal in hepatic coma. The level of aromatic aminoacids is increased but the level of branched chain aminoacids is decreased.

Thymol turbidity test: The turbidity produced in the serum sample on adding a thymol solution in barbitone buffer is estimated photometrically. The turbidity is increased in viral hepatitis, primary biliary cirrhosis, Multiple myeloma due to excess production of gamma globulins.

Zinc Sulphate turbidity test The turbidity produced in the serum sample on adding Zinc sulphate solution in barbitone buffer is estimated photometrically. The turbidity is increased in viral hepatitis, due to excess production of gamma globul

Tests based on synthetic function All plasma proteins except immunoglobulins are synthesized in the liver. therefore the measurement of serum proteins forms a reliable index of liver function. Serum albumin levels Albumin level is decreased in almost all liver diseases. A reversal of albumin globulin ratio is seen in Cirrhosis. This may be due to hypoalbuminemia and associated hypergammaglobulinemia. b) Serum total protein levels. In chronic liver diseases serum total protein levels are decreased.

c) Prothrombin time:
Prothrombin is synthesized in the liver and hence forms an useful indicator of liver function. Prolonged Prothrombin time due to vitamin K deficiency can be ruled out by estimating Prothrombin time before and after parenteral administration of vitamin K. In acute or chronic hepatocellular injury Prolonged Prothrombin time is seen even after administration of vitamin K indicating imminent hepatic failure and a poor prognosis.

Tests based on Detoxification functions

Hippuric acid excretion test:

Benzoic acid is converted to benzoyl Glycine (Hippuric acid) by conjugation in the liver and is excreted in urine. This forms an important test of liver function which tests its conjugation ability. In normal people almost 40% of sodium benzoate is excreted in urine within 60 minutes, while the time is prolonged in patients with hepatocellular injury.

Serum enzymes as markers of Hepatobiliary disease

Enzyme AST Normal range 0 to 40 IU/L Increased in Viral and toxic hepatitis(Highest increases)Slight elevation in Obstructive disease Viral and toxic hepatitis(Highest increases)Slight elevation in Obstructive diseaseMore than AST Highest levels in Obstructive Liver disease.Slight elevations are seen in Parenchymal liver diseaseElevations are also seen in cirrhosis due to increase in intestinal isoenzyme

ALT

0 to 40 IU/L

ALP

0 to 145 U/L

GGT

10 to 30 IU/L

Increased in Chronic alcoholism

5.5Nucleotidase

2 to 10 IU/L

Increased in Hepatobiliary disease Hepatic parenchymal disease

6.Lactate dehydrogenase 0 to 400 IU/L) (LDH