PEMERIKSAAN LABORATORIUM PADA

GANGGUAN HEPATOBILIER

Semester IV BLOK 245Indriani Silvia

FK UNSWAGATI 14 Mei 2012

Learning Objectives

Mampu menjelaskan tes fungsi hati

Mampu menjelaskan fungsi dan tujuan tes

fungsi hati

Memahami prinsip dasar dan cara kerja

Anatomi Hati

Fungsi Hepar• Hepar organ berukuran terbesar

organ interna paling kompleks• Seluruh darah dari intestin dan pankreas

hepar melalui sistem vena porta• Hepar organ multifungsi banyak fungsi

tubuh

1. Fungsi Metabolik karbohidrat, lemak, protein, mineral dan vitamin2. Fungsi Ekskresi pigmen empedu, garam empedu, kolesterol

ekskresi [pigmen empedu] intestin

3. Fungsi protektif dan Detoksifikasi Sel Kupfer hepar fagositosis benda asing

Contoh amonia didetoksifikasi menjadi bentuk urea dan dimetabolisme xenobiotik (detoksifikasi)

klirens hormon insulin, hormon paratiroid (PTH), estrogen, kortisol

4. Fungsi Hematologi dan Sintesis• pembentukan sel darah (saat embrio)• sintesis of protein plasma (albumin,

protrombin), hormon seperti angiotensinogen, insulin-like growth factor (IGF) dan triiodotironin

• destruksi eritrosit (Bilirubin)

5. Fungsi penyimpanan glikogen, vitamins A, D dan B12

6. Enzim serum penanda kerusakan hepar

Hepatic uptake of bilirubin and production of bile

Tes Fungsi Hepatobilier

• interpretasi risiko faktor, gejala klinis, faktor penyerta, pemeriksaan fisik

• menggambarkan adanya gangguan hepatobilier t.u kronis

• harus diikuti evaluasi/monitoring• tiap laboratorium nilai normal berbeda

.

Roberts E A , Sarkar B Am J Clin Nutr 2008;88:851S-854S©2008 by American Society for Nutrition

Struktur Subseluler Hepar

Bilirubin

Normal kadar bilirubin serum• Total bilirubin: 4 ̶ 19 mol/L• Conjugated

bilirubin/direk/glukuronida: 0 ̶ 4 mol/L

• Unconjugated bilirubin/indirek/kompleks bilirubin - albumin /bilirubin

hingga 12 mol/L

BILIRUBIN Serum dinilai menggunakan reaksi Van den Bergh

• Prinsip pemeriksaan asam sulfanilat dalam HCl dan

sodium nitrat + bilirubin azobilirubin (ungu)

Bilirubin serum metode Van den Bergh

• Conjugated bilirubin segera ungu

van den Bergh positif• Unconjugated bilirubin + alkohol

ungu positif indirek• Bila kadar conjugated & unconjugated

bilirubin ↑ segera ungu• + Alkohol intensitas ungu ↑ bifasik

Produksi bilirubin

kegunaan• sensitif, metode

noninvasif untuk skrining disfungsi hati

• menggambarkan adanya jenis gangguan hati

• menilai keparahan disfungsi hati

• dilakukan setelah ditentukan dugaan etiologi penyakit hati

kekurangan• sensitivitas ↓

Nilai normal padakelainan hati yang

berat

• tidak spesifik untuk disfungsi hati

• jarang menggambarkan diagnosis spesifik

Tes Fungsi Hati

Tes Fungsi HatiLiver chemistry test

Clinical implication of abnormality

ALT Hepatocellular damageAST Hepatocellular damageBilirubin Cholestasis, impair conjugation, or biliary

obstructionALP Cholestasis, infiltrative disease, or biliary

obstructionPT Synthetic functionAlbumin Synthetic functionGGT Cholestasis or biliary obstructionBile acids Cholestasis or biliary obstruction5`-nucleotidase Cholestasis or biliary obstructionLDH Hepatocellular damage, not specific

Tes Fungsi HatiMild

(times)Moderate

(times)Marked(times)

AST <2-3 2-3 to 20 >20

ALT <2-3 2-3 to 20 >20

ALP <1.5-2 1.5-2 to 5 >5

GGT <2-3 2-3 to 10 >10

Tes Fungsi Hatiklasifikasi

•fungsi sintesis albumin, PT•kerusakan sel & jaringan hepatik AST, ALT•kolestasis bilirubin, ALP, GGT

prothrombin time, albumin, bilirubin Prognosis

Albumin• dipengaruhi nutrisi, status volume,

integritas vaskular, katabolisme, hormon, ekskresi urin & feses

• tidak spesifik untuk kelainan hati

• t 1/2 (waktu paruh)19-21 hari– Bukan indikator bermakna untuk

kelainan hati yang akut

Pemeriksaan Bilirubin Urin

• Urin bilirubin• Bilirubin oksidasi + UV biliverdin

A.Percobaan Busa5 ml urin segar dalam tabung dicampur

(gerakan kuat) bilirubin + kuning

bilirubin - putih/kuning muda+ palsu [urobilin] ↓akriflavin, piridium

Pemeriksaan Bilirubin Urin• B Percobaan HarrisonPrinsip pemeriksaan:bilirubin + barium klorida 10% + Fouchet

warna hijau bilirubin

Cara kerja• 5 ml urin dalam tabung dicampur kuat.• + 5 ml lar barium klorida 10% saring.• Angkat kertas saring dari corong, dibuka

lipatannya, ditaruh mendatar, biarkan kering.• + 2 ̶ 3 tetes reagen Fouchet di atas

presipitat kertas saring hijau

Pemeriksaan Bilirubin Urin• C Modifikasi percobaan Harrison dengan potongan kertas saring

kertas saring tebal uk 10x1 cm (Schleicher dan Snull no 740) direndam di dalam lar barium klorida beberapa lama hingga diserap kertas saring

keringkan di lemari panas digunakan

Cara KerjaPotongan kertas saring dipegang dan sebelah lain dimasukkan ke dalam urin hingga 1/3 30” ̶ 2’Kertas diangkat biarkan hingga kering+ 1 tetes Fouchet Hijau (bilirubin +)

• Bilirubin zat lain kuning tua, kuning campur hijau, coklat

• Bilirubin glukorinida oksidasi+UV biliverdin (hijau)

bilisianin (biru) koletelin

(kuning)Interpretasi• Kadar rendah +• Kadar tinggi ++

Pemeriksaan Bilirubin Urin• C Cara dengan carik celupbilirubin + senyawa diazo pada carik celup

CatatanUrin segarUrin tidak segar hidrolisi atau oksidasi

Tes Fungsi Hati• mendeteksi abnormalitas dan meluasnya

kerusakan sel hati• Lebih sensitif dari gejala klinis• Tes fungsi hati terdiri atas - Total protein yaitu:

– Albumin and globulin– (Prothrombin Time, PT, masa protrombin)– Transaminases (AST & ALT) – Alkaline PO4ase– Bilirubin, biasanya dalam bentuk fraksi– Gamma Glutamyl Transpeptidase (GGT)

Total protein

• Not a very useful measure, non-specific; only provides information on:– General nutritional status– Severe organ disease (esp protein losing d/s)– Fractionated values of greater use

• Methods of measurement:– Electrophoresis followed by,– Precipitation, followed by,– Column separation.– Nitrogen content is usual method in automation

Total protein

• Ingat! Penilaian protein dalam serum hindari pengenceran protein

dengan antikoagulan• Precipitation is used to fractionate proteins

into albumin and globulin– + NaSO4, Na sulfite, Ammonium SO4, methanol globulin mengendap– Rasio A/G > serum protein

abnormal– Perubahan kadar albumin– Perubahan kadar globulin– Sintesis ↑ kadar ↑

Total protein

• Indeks refratif (bermakna bila > 2,5g/dL)• Panjang gelombang UV 280nm• Metode turbidimetrik• kolorimetrik – metode biuret

otomatis

Albumin dan globulin• Albumin

– Biasanya protein abundant dalam serum (120 mg/kg/hari)

– ↓albumin• Kerusakan sintesis (malnutrisi, malabsorpsi,

disfungsi hepatik, sirosis hati)• kekurangan (asites, protein losing-

nephropathy, enteropathy)• Edeme perifer albumin ↓

– Hingga 25% albumin pada hyperglikemia menjadi glikosilasi dengan HbA1c –fruktosamin

– monitoring DM

Albumin dan globulin• Albumin

– albumin• Tidak spesifik – dapat terjadi pada dehidrasi

atau artefak akibat penggunaan torniket

• Tipe globulin– 1-antitripsin (AAT)– 2-makroglobulin– haptoglobin– transferrin – seruloplasmin

1-antitripsin (AAT)

• > abundant 1-globulin• menghambat kerja tripsin• terdiri atas beberapa variasi genetik• AAT emfisema and neonatal

jaundice

2-makroglobulin

• non-immunoglobulin protein plasma jumlah terbanyak• sindrom nefrotik

Haptoglobin

• Another major 2 protein• Function – to combine with Hb released by RBC lysis to

preserve Fe and protein stores• Circulating half-life approx 4 days• in stress, infection, acute inflamm, tissue necrosis• ↓ post haemolytic episode• Useful to monitor slow rate of haemolysis i.e. fm

mechanical valves, exercise associated trauma, haemoglobinopathies

Ceruloplasmin

• Cu containing enzyme (ferroxidase) in serum

• ↓ in Wilson’s d/s

• Associated with chronic hepatitis (occ acute) and

may have neurologic/ psychiatric sequelae

-Fetoprotein• One of the major plasma proteins in foetal life• Function not known, similar structure to albumin• Falls thru-out gestation (~10,000 ng/mL at birth) and

by age one yr (<10 ng/mL – adult levels)• In acute hepatic injury AFP 10 – 20X upper ref

limits• Abt 10% pt with viral hepatitis have AFP• Fibrosis post chronic liver d/s, AFP • Used to screen and diagnose HCC & hepatoblastoma

Prothrombin Time• Most coag factors made in liver (particularly those assoc with

vitamin K)• Hence in liver d/s, coagulopathies are common• Commonly PT is used for detecting liver assoc coagulopathies• Best PT method not clear• PT INR is useful for monitoring oral anti-coag therapy, not very

useful for liver disease• An indirect test of hepatic synthetic function includes

administration of vitamin K (10mg) subcutaneously over three days. Several days later, the prothrombin time may be measured. If the prothrombin time becomes normal, then hepatic synthetic function is intact. This test does not indicate that there is no liver disease, but is suggestive that malnutrition may coexist with (or without) liver disease.

Transaminases

• Tests of liver injury• Hepatocytes contain high levels of enzymes

that can leak into the plasma when there is liver injury

• Enzymes found in hepatocytes are:– Cytoplasmic = LDH, AST, ALT– Mitochondrial = ASTm

– Canalicular = ALP, GGT

Alanine Aminotransferase (ALT)/SGPT

• Primer penyakit hati, monitoring terapi hepatitis, active postnecrotic cirrhosis & efek terapi

• ↑ inflamasi, nekrosis

• Sel rusak ALT dilepaskan ke sirkulasi darah

• Perubahan kadar ALT kadang tidak spesifik

• Tapi ALT sensitif untuk kerusakan hepatosit

• ALT dapat dibedakan antara hemolytic jaundice & jaundice

Alanine Aminotransferase (ALT)• Increased ALT levels are found in the following

conditions:- Hepatocellular disease - Active cirrhosis (mild increase)- Metastatic liver tumor- Obstructive jaundice or billiary obstruction (mild to moderate increase)- viral, infectious or toxic hepatitis (30-50x normal)- infectious mononucleosis)

Aspartate Aminotransferase (AST)/SGOT

• Also reflects damage to the hepatic cell• It is less specific for liver disease• It may be elevated and other conditions such as a myocardial

infarct and muscle disease • Although AST is not a specific for liver as the ALT, ratios

between ALT and AST are useful to physicians in assessing the aetiology of liver enzyme abnormalities

• Viral heptitis, mononucleosis, and acute hepatotoxicity typically show elevations in ALT that are equal to or greater than AST elevations (AST/ALT less than or equal to 1.0)

• ALT is elevated to a lesser degree than AST in alcoholic liver disease and cirrhosis, passive congestion, bile duct obstruction, or metastatic tumor to the liver (AST/ALT greater than 1.0)

Measurement• Uses coupled enzymatic reactions with NADH as final

reaction product measured• Reagents with NH4

+ should be avoided as it may artificially the AST/ALT values

• Values also affected by buffers

Spesimen

• Stabil dalam whole blood selama 24 jam (lalu karena dieksresikan dari RBC)

• AST/ALT stabil pada 4oC hingga 3 minggu• AST stabil dengan dibekukan (freezed)• ALT dapat↓ dengan freezing sesuai buffer

uyang digunakan

Alkalin Fosfatase• Sumber: hati, tulang, plasenta dan intestin• ↑ ALP pada kelainan hati sintesis sel di

kanalikuli bilier ↑ kolestasis (intra atau ekstra hepatik)

• ALP ↑ 2x nilai normal kolestasis• ALP ↑ kelainan hati infiltratif space

occupying lesions (SOL) tumor• Tulang yang sedang tumbuh memerlukan ALP• ↑ serum ALP osteoblast-rapid growth,

penyembuhan fraktur, keganasan tulang, Paget’s disease, riketsia

• Plasenta ALP• inflammatory bowel disease (kolitis ulserativa)

ALP↑

Enzim Gamma Glutamyl Transferase (GGT)

• GGT sintesis glutation tripeptida• GGT hati, ginjal, pankreas, sel

intestin, dan kelenjar prostat• ↑(> 10 - 30 IU/l) alkoholik kronis, kelainan pankreas, infark

miokard, gagal ginjal, penyakit paru obstruktif kronis (PPOK), DM

• Penyakit hati GGT ↑ = ALP• Penyakit hati alkoholik GGT ↑= jumlah

alkohol yang dikonsumsi

Thank You