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INVESTIGATIONS OF

INVESTIGATIONS OF. LIVER DISORDERS. BLOOD EXAMINATION. 2. CHEST X- RAY. 3. LIVER FUNCTION TESTS. 4. IMAGING STUDIES. Non invasive Invasive. 5. LIVER BIOPSY. Blood Examination. Routine examinations Infections C/c liver disease Tumor markers. Viral hepatitis.

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INVESTIGATIONS OF

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  1. INVESTIGATIONS OF LIVER DISORDERS

  2. BLOOD EXAMINATION 2. CHEST X- RAY 3. LIVER FUNCTION TESTS 4. IMAGING STUDIES • Non invasive • Invasive 5. LIVER BIOPSY

  3. Blood Examination • Routine examinations Infections C/c liver disease • Tumor markers

  4. Viral hepatitis • Hepatitis A - IgM Anti. HAV antibodies • Hepatitis B – HBs Ag – ‘Australia antigen’ HBe Ag – for replication &infectivity Anti HBS – immunity to HBV • Hepatitis C – Anti.HCV antibody • Hepatitis D – PCR HDV – RNA • Hepatitis E – Anti HEV anti bodies

  5. Tumor Markers Alfa - feto protein In Hepatocellular carcinoma Above 500ng/dl Also in Germ cell tumors Secondaries Cirrhosis Des-y-carboxy prothrombin Glypican-3

  6. CHEST X-RAY • Canon ball secondaries’. • Pleural effusion.

  7. Liver Function Tests Tests based on the excretory function Tests based on the metabolic capacity of the liver Tests based on synthetic function of liver Tests based on serum enzymes

  8. TESTS BASED ON EXCRETORY FUNCTIONS

  9. SERUM BILIRUBIN Normal value Total - 0.2- 0.8 mg/dl Unconjugated bilirubin - 0.2 – 0.6 mg /dl Conjugated bilirubin - 0 – 0.2 mg / dl

  10. Estimation • Vanden Bergh reaction Diazotized sulfanilic acid + bilirubin azobilirubin (purple) Absorbs light of 540nm

  11. Conjugated / Direct bilirubin - Reacts immediately on mixing with reagent i.e., within 1 min. Elevated in obstructive & hepatocellular jaundise • Unconjugated / Indirect bilirubin • Reacts on addition of alcohol; reacts within 30 min. Elevated in haemolytic jaundice Biphasic reaction

  12. Bilirubin – Fouchet’s test Fouchet’s reagent – FeCl3 in trichloroacetic acid. Urobilinogen – Ehrlich test Ehrlich’s reagent – paradimethyl amino benzaldehyde in hydrochloric acid. Bile salts – Hay’s test Urine Analysis

  13. Obstructive jaundice Bilirubin - + ve Bile salts - + ve Uroblinogen - - ve • Pre hepatic jaundice Urobilinogen - +ve Bile salts - -ve Bilirubin - -ve

  14. Dye excretion • Dyes used - Indocyanin green - Sulfobromophthlein • Done for - hepatic blood flow - portal blood flow - Porto systemic shunt - surgical shunt evaluation

  15. Tests for metabolic capacity • Amino pyrine breath test – using C 14 labeled aminopyrine. Aminopyrine De methylation 14CO2 liver • Normal people expires – 6.6 % +/- 1.3 % • in 2 hrs. Uses - assess residual functional liver cells. - prognosis of a disease.

  16. Galactose tolerance testPlasma Amino AcidsLidocain clearance testMetabolite tested is Monoethylglycinexlide

  17. Tests To Assess Synthetic Function • Serum albumin normal 35 -50 gm /dl albumin decreased; A/G ratio reversal • Prothrombin time normal  12 -16 sec. • Clotting factors - 1,2, 5, 7, 9, 10, 12, 13 are synthesized by liver. • Vitamin K dependent clotting factors – 2, 7, 9, 10.

  18. Tests based on serum enzymes

  19. AMINOTRANSFERASES • Alanine amino transferase (ALT/SGPT) • Aspartate Aminotransferase (AST/SGOT) Normal value : 5 – 40 IU/L Elevated in - hepatitis - cirrhosis - malignancy of liver AST/ALT ratio

  20. Markers of obstructive liver diseases • Alkaline phosphatase (ALP) • Seen in the lining epithelium of biliary tract. Normal value – 30-130 IU / L Elevated in • Liver disorders : Biliary obstruction or liver infilteration • Bone disorders • Normal in children Regans isoenzyme

  21. Gamma glutamyl transferase To confirm the organ specificity of ALP Normal value –10 – 48 iu /L Elevated in - c/c alcoholism - Biliary obstruction 5’ Nucleotidase Normal: 0-11 iu/l

  22. CHILDS CLASSIFICATION OF HEPATOCELLULAR DYSFUNCTION

  23. Immunological markers • Antinuclear antibodies • Antimitochondrial antibodies • LKM antibodies • Liver membrane antibodies

  24. LIVER BIOPSY

  25. INDICATIONS FOR LIVER BIOPSY • Determine the cause of abnormal hepatic biochemical tests. • Diagnosis of multi system infiltrative, inflammatory or granulomatous diseases. • Diagnosis of neoplasms. • Grading and staging of c/c hepatitis. • Evaluation of cholestatic & alcoholic liver disease. • Evaluate the status of liver following transplantation; evaluate donor liver prior to harvesting.

  26. TYPES • Trans cutaneous • Ultra sound or CT guided • Laparoscopic • Trans jugular approach

  27. Per Cutaneous Liver Biopsy Procedure In the space b/w ant. Axillary line & mid axillary line b/w 6-9 ribs.

  28. Menghini needle Vilm –Silverman needle Using Suction technique needlesCutting technique needles Ex. Menghini needle Vilm – silverman needle Klatskin needle Tru – cut needle jamshidi needle

  29. Contraindications • Absolute . Bleeding disorder • Hydatid cysts • Haemangioma / vascular tumors • Uncooperative patient • Unavailability of blood transfusion support • Relative • Ascites • Infections of right pleural cavity • Infections below diaphragm

  30. Complications • Pain • Hemorrhage • Intra hepatic • Intra peritoneal • Hemobilia • Bile peritonitis • Bacteremia • Sepsis & abscess • A-V fistula • Injury to other organs

  31. Trans Jugular Liver Biopsy Indications • Significant coagulopathy • Moderate to severe ascites • Fulminant hepatic failure • Failed per cutaneous attempt

  32. PROCEDURE Obtaining liver tissue from within the vascular system. Through percutaneous puncture of right Int. Jugular vein. Passage of a catheter into right hepatic vein Biopsy of liver using a special needle Under fluoroscopic guidance.

  33. COMPLICATIONS • Neck hematoma • Transient Horner’s syndrome. • Transient dysphonia • Cardiac arrhythmia. • Perforation of liver capsule.

  34. Laparoscopic liver biopsy • Indications • Diagnosis of peritoneal metastasis • Chronic liver disease • Staging of malignancies • non conclusive imaging studies • Contraindications • Severe cardiopulmonary failure • A/C M.I • Intestinal obstructions • Bacterial peritonitis

  35. COMPLICATIONS • MAJOR • Abdominal viscus perforation • Bleeding from liver biopsy site • Hemobilia • Spleen lacerations • MINOR • Ascitic fluid leakage • Abdominal wall hematoma • Post laparoscopic fever

  36. NON INVASIVE IMAGING OF LIVER • X ray • Ultrasonography • Hepatic Doppler sonography • CT /MRI • MRCP

  37. X RAY Hepatobiliary calcifications Portal venous gas shadow Abscess Pneumobilia Porcelain gall bladder

  38. Porcelian gallbladder pneumobilia

  39. Ultrasonography • Most commonly used imaging modality for liver pathologies. • Best evaluated with a 3 – 5 MHz transducer.

  40. Normal liver

  41. Fatty liver

  42. Hepatic cyst

  43. Hydatid cyst

  44. Hepatic candiadisis

  45. Cirrhosis

  46. Hepatocellular carcinoma

  47. Metastasis

  48. Normal Gallbladder

  49. Gall stones

  50. Gallbladder polyp

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