hepatobilliary sistem.pdf | Alanine Transaminase | Liver

Hepatobilliary Drh. Ahmad Fauzi, M.Sc

ANATOMI

MORPHOLOGIC CLASSIFICATION OF BILIARY DISORDERS OF THE CANINE AND FELINE LIVER The biliary disorders can be grouped into four major categories: 1. Biliary cystic diseases and biliary atresia, including solitary cysts and congenital cystic disease of the liver, with the following proposed terminologies: congenital dilatation of the large and segmental bile ducts, juvenile polycystic disease/congenital hepatic fibrosis, and adult polycystic disease. 2. Cholestasis, including (I) cholestasis (bilirubinostasis), (II) intrahepatic cholestasis, (III) extrahepatic cholestasis (acute and chronic stage) 3. Cholangitis, classified as (I) neutrophilic cholangitis, usually from ascending bacterial infection, (II) lymphocytic cholangitis in cats, (III) destructive cholangitis, and (IV) chronic cholangitis associated with liver fluke infection. 4. Diseases of the gall bladder, including (I) cystic mucinous hyperplasia (mucocele), (II) cholecystitis (neutrophylic, lymphoplasmacellular, and follicular), and (III) infection of the gall bladder

Causes of Acute (A) and Chronic (B) Hepatitis Specific Acute Hepatocellular Necrosis and Inflammation Infectious • Infectious canine hepatitis due to CAV1 • Canine and feline herpes viruses • Feline infectious peritonitis virus • Clostridium piliformis (Tyzzer's disease) • Leptospirosis • Helicobacter canis • Septicemic bacterial diseases • Toxoplasma gondii

Toxic

• Amanitum spp. (mushroom) • Cyanophyceae (blue green algae) • Benzodiazepine (diazepam: idiosyncratic drug reaction in cats) • Acetaminophen • Trimethoprim sulfonamide, carprofen, amiodarone

Causes of Acute (A) and Chronic (B) Hepatitis chronic Hepatitis • Many causes remain undetermined but may be associated with leptospirosis, CAV1 infection, anticonvulsant drugs (in dogs) such as primidone, phenytoin, phenobarbital, and aflatoxicosis. Chronic hepatitis and cirrhosis are rarely seen in cats. • Copper-associated: genetic (Bedlington Terrier), familiar (West Highland White Terrier, Skye Terrier, Dalmatian, Labrador Retriever, probably other breeds)

History, Clinical Signs, and Physical Findings in Hepatobiliary Disease • The liver plays a central role in a diverse array of processes including carbohydrate, lipid, and protein metabolism; detoxification of metabolites and xenobiotics; storage of vitamins, trace metals, fat, and glycogen; fat digestion; and immunoregulation. • Specific signs of hepatobiliary disease such as: icterus, hypoglycemia , bleeding tendencies, hepatic encephalopathy (HE), or ascites, which reflect exhaustion of the liver's functional reserves, occurs late in disease progression.

Clinical Signs

Clinical Signs

Bilirubin metabolism • Major metabolite of heme • Heme is found in hemoglobin, myoglobin and cytocrome. • Most of daily production (0.2 to 0.3g/dL) is derived from breakdown of senescent erythrocytes • Rate of systemic bilirubin production is equal to the rates of hepatic uptakes, conjugation, and biliary excretion.

Production of bilirubin

PATHOPHYSIOLOGY OF JAUNDICE • Disturbance in bilirubin production or clearance. • It is characterized by yellow color of white of the eyes (sclera) and skin • Serum bilirubin levels rise above 2.0 to 2.5 mg/dL; level as high as 30-40mg/dL can occur with severe disease • ↑ also called as hyperbilirubinemia.

MECHANISM OF JAUNDICE • Excessive production of bilirubin • Reduced hepatic uptake • Impaired conjugation • Decreased hepato-cellular excretion • Impaired bile flow (both intrahepatic and extrahepatic)

Aetiology of jaundice Jaundice

Pre-hepatic

Post-hepatic Hepatic

SIRKULASI NORMAL BILIRUBIN

IKTERUS INTRAHEPATIK

IKTERUS POSTAHEPATIK/OBSTRUKSI POSTHEPATIK

Clinical Enzymology • Evaluation of serum values of hepatobiliary enzymes—such as 1. alanine aminotransferase (ALT)/Serum Glutamic pyruvic transaminase (SGPT) 2. aspartate aminotransferase (AST)/ Serum Glutamic oxaloacetic transaminase (SGOT) 3. alkaline phosphatase (ALP) 4. γ-glutamyl transpeptidase (GGT)

LABORATORY INVESTIGATION • Usually, the following examinations are taken: - FBC (hemolysis) -serum aminotransferase (AST,ALT) - Serology for hepatitis including HCAb,HBsAg, HBcAb - ALP: if elevated or if an obstruction is suspected, images of the bile ducts should be obtained. - GGT - Fractionated bilirubin

Laboratory differential diagnosis of jaundice Hemolytic Features

Bilirubin usually