00:01
Hello! Welcome to Hepatobiliary diseases.
00:04
Here our topic at first will be viral
hepatitis.
00:08
Remember that when we discuss hepatitis
there could be many, many causes as we go
through our topic of hepatitis.
00:17
At first it will be viral, but it could be
autoimmune.
00:19
It could be alcohol, could be many causes do
not always assume that it's viral.
00:25
Let's begin. The liver tests that you should
be familiar with, known as your liver
function tests include the following.
00:34
In hematology, we talked about bilirubin
quite a bit, and here we talk about bilirubin
as being part of prejudice or pre hepatic
jaundice.
00:44
Hepatic jaundice and post hepatic jaundice.
00:47
Here with bilirubin accumulating.
00:51
Not exactly sure as to what part of
bilirubin metabolism could be affected.
00:55
What do you mean, Dr. Raj?
Watch. Say that you brought bilirubin.
01:01
Unconjugated type.
01:02
An indirect is what is what we use
clinically.
01:06
And you bring this lipid soluble substance
to deliver with the chaperon.
01:10
The albumin then drops it off.
01:12
Obviously the first step here by the liver's
to make sure that it conjugates it correct.
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What does conjugate mean to you.
01:20
It means a turning something that's lipid
soluble into water soluble.
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And why is that our objective.
01:27
Why is this objective so important.
01:29
Because we're trying to at some point get
this bilirubin out into excretion.
01:33
And in order for you to get bilirubin into
the urine, you must conjugate it at some
point in time. My point is this when you
have liver disease, maybe perhaps the enzymes
have been affected.
01:46
The enzyme responsible for conjugation is
UDP glucuronosyltransferase.
01:50
Without going into that type of detail.
01:53
If the liver is damaged sufficiently and the
enzymes are not working properly, then what
component or what fraction of a bilirubin
are you then noticing?
Good the unconjugated bilirubin.
02:07
Or let's say that there is enough damage to
the liver that now at this point the entry
point into bile has been blocked.
02:17
But remember bilirubin is part of your bile
as well.
02:21
So therefore now you could get conjugated.
02:24
However, the type of bilirubin that you're
looking for laboratory wise could be
conjugated. So what's the point.
02:31
And what are you paying attention to on your
boards and on your wards?
You can have a mixed picture of bilirubin.
02:40
Or called jaundice.
02:42
When you have liver disease, keep that in
mind.
02:45
If that is not clear, make sure that you go
back and take a look at proper and full
bilirubin metabolism.
02:51
So what I have just discussed with you
medically, clinically makes a lot more sense.
02:58
Next. My topic is liver function tests.
03:01
What if the liver is damaged sufficiently
enough where the liver inadequately doesn't
put out albumin?
Welcome to something like cirrhosis.
03:15
Anything that causes end stage liver
disease, or if there is sufficient liver
damage, there's every possibility that
albumin could be diminished.
03:23
Mm. What does albumin contribute
physiologically in your circulation.
03:28
What part of your starling's forces.
03:31
Good oncotic pressure.
03:33
Thus, if albumin is not present, oncotic
pressure drops.
03:38
Where is my fluid now?
Escaping into intra tissue.
03:44
There are two tests or coagulation tests.
03:48
You notice I didn't say platelet test,
right?
What's the platelets platelet test that
you're extremely familiar with or should be.
03:55
That's bleeding time and hemodynamics.
03:58
We talked about platelets.
04:00
I'm not going to bring that up here.
04:02
But either platelet dysfunction or
quantitatively you have thrombocytopenia.
04:06
Then the bleeding time will be affected.
04:07
Here. However the coagulation factors that
you should be familiar with include well from
the liver what are you synthesizing to
seven, nine and ten divided by k dependent
factors on one end pro coagulation.
04:25
And what are the two anticoagulation factors
that deliver produces?
Protein C and protein S.
04:33
From henceforth.
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Whenever you think about the liver, remember
there are pro and anti coagulant factors that
are in fact being secreted from it.
04:42
Correct. Next.
04:45
Clinically speaking, which of the two tests
are you going to measure of your coagulation
to tell you that the liver may or may not be
functioning properly?
It's PT prothrombin time.
04:58
Inr international normalized ratio.
05:02
What is it that you want to know in terms of
its actual time?
11 to 15 seconds.
05:09
You know that for your boards you'll be in
good shape.
05:12
Thus, if the liver is not functioning
properly, the synthesis of your coagulation
factor drops.
05:19
What then happens to your PT?
Increases. Have alt.
05:26
This is your alanine or alkaline alanine
type of aminotransferase.
05:30
So you have the two transaminases Alt and
AST.
05:34
And the ratio here do become very important
since our topic in this section is going to
move into viral hepatitis, would you please
be able to tell me which one of these
transaminases would be elevated?
More so would it be Alt or AST in viral
hepatitis?
Good alt.
05:53
Just to make sure that we're clear and to
have a little bit of fun with this.
05:58
I want you to toast to assist.
06:01
Toasting. What?
Alcohol. So whenever you have alcohol
induced hepatitis there, the assist will be
increased versus alt.
06:12
2 to 1 ratio.
06:14
Continue. When does alkaline phosphatase
come into play?
And do not confuse the ALP with Alt.
06:24
Alp alkaline phosphatase would come into
consideration if the biliary tree has been
affected. Obviously, the liver and the
biliary tree are one unit.
06:38
You cannot separate one from the other if
there's enough damage that's taking place to
the liver. Understand that you are then
going to affect your bile or biliary
canaliculi. And so therefore may cause
damage or injury to the biliary system,
therefore increasing ALP.
06:56
Just to make sure we're clear, would you
tell me as to what other set of diseases
under a different type?
But still ALP would be used for obviously
bone disease.
07:08
Now the two types of liver function are p t
and albumin.
07:11
So those are the two that you definitely
want to focus upon.
07:14
But absolutely understand that each one of
the components that we're dealing with here
will play an important role, so that you can
diagnose your patient properly.
07:23
The other is only signify altered function
and do not correlate with overall synthetic
activity of the liver. So of all of these,
the two that actually give you proper
functioning of liver include p, t and
albumin.