enzyme presentation

8/10/2019 Enzyme Presentation

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CASE 3-ENZYMESJaneel McDonaldYnolde Leys



A 33 year old man presented with upperabdominal pain and progressive jaundiced of2 months duration !ive months earlier he

jumped from the third floor of a psychiatrichospital sustaining multiple factures of hisface" cervical and lumbar spines and lowerlimbs #n e$amination he was icteric and

moderately tender in the epigastrium Dar%stools were present per rectum



RESULTS 'a (3) mmol*L +(3, - (.,/

0 . 1 mmol*L +3 , - , / l )) mmol*L +), - ( ,/

4 # 35 2, mmol*L +2 - 26/7rea 1 3 mmol*L +2 , - 1 8/

reat ((2 9mmol*L +1 - (2./ #smolality 26, m#smol*%g +262 - 2),/

a 2 ., mmol*L +2 2, - 2 8,/:# . ( mmol*L + 6 - ( ./ALP 510 U/L (15 - 105)ALT 181 U/L (7 - 40 U/L)Bili (T) 340 µmmol/L ( 18)Albumin . g*L +365,2/



;'<=>:>=<A<;#' #!>=?7L<?



ABN!RMAL RESULTS AL: ,( 7*L +(, 5 ( ,/ ↑ AL< (6( 7*L +8 5 . 7*L/

↑

@ili +</ 3. 9mmol*L + (6/ ↑



"NTERPRETAT"!N <he results show a mi$ed cholestatic and

hepatocellular damage picture because ofsignificant elevation in both AL< BAL:



TRANSAM"NASES AL< B A?< are commonly used to indicate

hepatocellular destruction @oth are found in the hepatocyte and are

released during cell damage but AL< is morespecific for liver damage because A?< ispresent in other locations eg ardiac"s%eletal muscle and >@



ALP Located in membranes" specifically the brush

borders of the : < of the %idney" the smallintestinal mucosa" both the sinusoidal and

canalicular surfaces of the hepatocyte" inosteoblasts in bone and in the placenta



;mportant in the formation of new bone byosteoblasts

@oth bone and liver have AL: <o distinguish

between the two one must do estimation ofplasma AL: ;soenCymes to determine theorigin of an isolated high AL: level



B"L"RUB"N <otal @ili Direct E;ndirect @ilirubin +'/ < bilirubin (6 9mmol*L

Jaundice can be prehepatic" intrahepatic "#bstructive*e$trahepatic

;t becomes obvious in s%in and sclera whenthe levels e$ceed , umols*L



#"$$ERENT"AL #"A%N!S"S holestatic Jaundice Drug ;nduced hepatitis +possibly due to anti5

psychotic medication/



!T&ER CAUSES $!R "NCREASE#ALP @one disease 5 reflects increased osteoblastic

activity i e " bone synthesis

Active bone growth +young children" atpuberty" ' li*+ , . 222 /

*NB . Patient sustained multiple factures to his face, cervical and lumbar spines and lowerlimbs.



F primary bone tumours +osteogenic sarcoma/F secondary tumours evo%ing a sclerotic response

e g " prostatic and breast metastasesF ric%ets +children/ and osteomalacia +adults/F :agetGs disease of bone +especially elderly men/F long5standing primary or secondaryhyperparathyroidism +e g " chronic renal diseasewhere calcium is resorbed from bone" leading torenal osteodystrophy/



"NCREASE# ALP C!NT # Li i 5 classic mar%er of cholestasis

due to e$tra5hepatic +pancreatic A"gallstones/ or intra5hepatic +drugs"

inflammation/ obstructionH=levated liver AL: without jaundice suggests IF ;ntermittent or incomplete obstruction+gallstone/

F ;ntra5hepatic space5occupying mass+tumour/



CAUSES $!R #AR6 ST!!L( 7pper ; bleed2 olorectal A ->ight colon3 Diet - ;ron rich foods" @eet"



$URT&ER "N EST"%AT"!NS =ndoscopic retrograde

choledochopancreatography +=> :/confirmed haemoblia and demonstrated

e$trinsic compression of the pro$imalcommon bile duct and left intrahepatic duct



&AEM!BL"A 4aemoblia is defined as bleeding into the

billiary tree auses may includeI

5<rauma5;nstrumentation eg => :5 holelithiasis5;nflammation5<umor

;t can present as an upper ; bleed @looddraining via the common bile duct into theduodenum



&AEM!BL"A C!NT # linical feature55K uin%e sK triad ofupper abdominalpain" upper gastrointestinal

haemorrhage and jaundice is classical but onlypresent in 22N cases



$"NAL #"A%N!S"S ! . i C'ol i

aused by traumatic injury to the liver andcommon bile duct

<rauma leads to the formation of haemobiliawhich was seen as melena

enzyme presentation

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