CHEMICAL

PATHOLOGY OF LIVER
DISEASES
BY
DR Atiba Adeniran Samuel
MB;BSilorin, PGDcardiff, FMCPath
Hepatic Lobule
 Based on the differential blood flow to the
acinus, it is divided into 3 functional zones
• periportal highest oxygen content: this
zone is least susceptible to ischaemic attack
• mediolobular intermediate
• centrilobular lowest oxygen content, most
susceptible to ischaemic damage.
This zone is most involved in drug metabolism,
most susceptible to drug-induced damage
Liver Acinus
METABOLIC FUNCTIONS OF THE LIVER

 Glycolysis, the Krebs cycle, gluconeogenesis,

glycogen synthesis and glycogenolysis,
lipogenesis, ketogenesis, amino acid
synthesis and degradation, and protein
synthesis all take place in the hepatocytes.
 Hepatocytes also metabolise and detoxify
endogenous (haem) and exogenous products
(drugs), which are then excreted via the
biliary tree
BILIRUBIN METABOLISM
Sources of Bilirubin
 Haemoglobin : The breakdown of RBC releases
haemoglobin
 It is also released from ineffective erythropoiesis
 Other haem containing proteins e.g. myoglobin
and cytochrome P450
 About 70 to 80% of daily bilirubin production is
derived from the breakdown of senescent red
blood cells, while the remainder is derived from
ineffective erythropoiesis and the breakdown of
other haem-containing proteins.
Formation of Bilirubin:

 Globin and Haem are formed from breaking down of

haemoglobin
 Globin (a protein) is broken down to its constituent amino
acids.
 Haem (a 4 ring structure containing Fe at its centre) is broken
down (via biliverdin) to carbon monoxide, iron and bilirubin.
 The bilirubin at this stage is termed unconjugated bilirubin.
 Unconjugated bilirubin is hydrophobic in nature strongly bind
to albumin in it hydrophobic site
 Some drugs displace it from its albumin binding site e.g
salicylate or any of the sulphonamides.
 It is highly neurotoxic causing kernicterus when deposited in
the cell membranes of basal ganglia
Unconjugated Bilirubin Uptake by the Liver
 The unconjugated bilirubin - albumin complex is carried in the plasma to the
hepatic sinusoids.
 Within the hepatocyte the unconjugated bilirubin is bound to ligandin

Conjugation of Bilirubin by the Liver

 The bilirubin is then conjugated with glucuronic acid by UDP-glucuronyl
transferase (UDPGT I) to bilirubin monoglucuronide (BMG) and by UDPGT II
to bilirubin diglucuronide (BDG).
 Conjugated bilirubin is more water soluble
 Under normal circumstances there is no conjugated bilirubin present in
plasma
 Conjugated bilirubin is transported out of the liver cells into the bile canaliculi
 This is a rate -limiting step in bilirubin metabolism
 Bilirubin along with bile flows through the canaliculi, into the bile ducts, and
finally into the duodenum
 In the GIT, bacterial flora convert conjugated bilirubin
to urobilinogen.
 Most of the urobilinogen (colourless) is further
converted by colon bacteria to urobilin and stercobilin
(brown).
 About 20% of urobilinogen in the small intestine is
reabsorbed into the portal circulation and re-excreted
back to the intestine (enterohepatic circulation).
 Some urobilinogen appears in normal urine but
becomes excess if re-uptake is defective as a result of
liver damage or an increased bilirubin production
BILE ACID METABOLISM

Formation of Bile Acids

 The primary bile acids are chenodeoxycholic acid and cholic acid, they
are metabolic products of cholesterol from the liver.
 The primary bile acids are made more soluble by conjugation with
glycine or taurine.
 Conjugated bile acids are transported out of the liver cells into the bile
canaliculi
 In the GIT, bacterial enzymes deconjugate and α dehydroxylate the
primary bile acids and convert them to the secondary bile acids
lithocholic acid and deoxycholic acid.
 Most of the bile acids in the GIT are reabsorbed into the portal circulation
(75% in the ileum and 10% in the colon), taken up by the liver again and
re-excreted (enterohepatic circulation). Normally a small amount
escapes into the systemic circulation. Any form of obstruction of biliary
tree causes reflux of bile acid in the system
BIOCHEMICAL TESTS OF LIVER FUNCTIONS

Bilirubin
 Normal serum total bilirubin <17 μmol/l
 Normal urine contains no bilirubin, since unconjugated bilirubin is
albumin-bound and not filtered.
 Increased amounts of unconjugated bilirubin are found in plasma in:
. Increased bilirubin production
. Decreased uptake or conjugation of bilirubin
. in generalised hepatocellular dysfunction
. in specific rare inherited syndromes (Gilbert’s and Criggler-Najjar
syndromes).

 Increased amounts of conjugated bilirubin are found in the plasma (and

urine) in: Decreased excretion of bilirubin as seen in obstructive liver
disease and in specific rare inherited syndromes (Rotor’s and Dubin-
Johnson syndromes).
Urine Urobilinogen
 Normal urine contains some urobilinogen.
 Increased amounts of urobilinogen are found
in the urine in:
• Increased bilirubin production.
• Decreased re-uptake into liver due to
hepatocellular dysfunction (but not if
obstruction prevents bilirubin to reach GIT).
Liver Enzymes
Enzymes Reflecting Liver Cell Damage

 Aspartate transaminase (AST) has widespread

tissue distribution including liver, red blood
cells, skeletal and cardiac muscle.
 Alanine transaminase (ALT) is more liver-
specific.
 Lactate Dehydrogenase (LD or LDH) has
widespread tissue distribution including liver,
red blood cells, skeletal and cardiac muscle..
The LD5 isoenzyme is found in the liver and
skeletal muscle only
Enzymes Reflecting Cholestasis

 Alkaline phosphatase (ALP) has widespread

tissue distribution including liver, bone,
placenta and GIT. It is released into plasma in
cholestasis.
 Gamma-glutamyl transferase (GGT) is more
liver-specific. Serum level increased by
cholestasis or chronic ingestion of alcohol,
barbiturates, phenytoin and other drugs
which induce the enzyme.
Plasma Proteins

 Albumin is decreased in chronic liver disease, but is

insensitive as an index of liver function.
 Clotting factors have short half-lives, e.g. factor VII t½ = 4h.
The prothrombin time (INR) and partial thromboplastin time
(PTT) may be prolonged in liver disease
 Immunoglobulins show a generalised increase (polyclonal) in
chronic liver disease, especially cirrhosis.
• In primary biliary cirrhosis IgM is characteristically increased.
• In alcoholic cirrhosis IgA is characteristically increased
• In autoimmune chronic active hepatitis IgG is particularly
increased
 Alpha-foetoprotein (AFP) is the embryonic form of
albumin, normally absent from plasma. It is increased
markedly in primary liver cell carcinoma as a result of
reversion of the malignant cells to a de-differentiated state.
 Also produced by some germ cell tumours (e.g. teratoma).
 Moderate elevations may occur when liver tissue is
regenerating, such as in the recovery stage after hepatitis
or in cirrhosis.
 Alpha-1 antitrypsin deficiency is a genetic disorder which
presents with childhood cirrhosis and severe emphysema in
early adulthood.
 Ferritin is the form in which iron is stored in the liver.
LIVER DISORDERS
Jaundice
 This is the yellow appearance of skin and
sclerae due to the presence of an excessive
amount of bilirubin (jaundice becomes
clinically visible when serum bilirubin is >40
μmol/l).
 The liver has a large reserve capacity -
jaundice only appears with severe
impairment of liver function
Classification of causes of jaundice

 A. Prehepatic Jaundice (increased production of bilirubin)

 Haemolytic Disorders
 • Abnormal haemoglobins (e.g. sickle cell anaemia).
 • RBC membrane defects (e.g. hereditary spherocytosis).
 • Malaria.

 Ineffective Erythropoiesis
 • Megaloblastic anaemias.


 B. Intrahepatic Jaundice (decreased handling of bilirubin by the liver)
 - Decreased uptake of bilirubin
 - Decreased conjugation of bilirubin
 - Decreased excretion of bilirubin into bile canaliculi

 Defect In Uptake / Conjugation Of Bilirubin
 GILBERT’S SYNDROME
 CRIGGLER-NAJJAR SYNDROMES :

 Defect in Excretion of Bilirubin into Bile Canaliculi
 DUBIN-JOHNSON and ROTOR’S SYNDROMES :
 • Benign inherited disorders.
 • Increased levels of conjugated bilirubin in serum and urine.
 • Due to impaired excretion
ACUTE VIRAL HEPATITIS

 This is a common infectious disease worldwide.

 Clinical severity varies from asymptomatic,
through mild hepatitis, to severe fulminant
hepatitis which can be fatal.
 It is responsible for the majority of chronic liver
disease, which in turn may be associated with
hepatocellular carcinoma.
 Causes are hepatitis A and B (commonest), Non-
A, Non-B hepatitis (Hepatitis C, D and E viruses)
EBV, CMV
Biochemical Features in Hepatitis:

Bilirubin
 increased unconjugated bilirubin throughout, and increased
conjugated bilirubin especially during obstructive phase.
 Urine positive for bilirubin, and urobilinogen increased due to
impaired re-uptake of urobilinogen by liver.
ALT and AST : Early rise in serum transaminases reflecting
hepatocyte damage. Start to rise before onset of jaundice and
it may be elevated without jaundice. In massive hepatic
necrosis transaminase levels may suddenly decrease (grave
prognostic sign)
ALP and GGT : Not greatly elevated early. Later marked
increases as intrahepatic cholestasis develops due to swelling
of cells
Plasma proteins
 Albumin only slightly decreased due to long half-
life. It may be normal depending on the severity
 Immunoglobulins: early increase in IgM, later
IgG. Smooth muscle auto-antibodies may appear.
 Decreased prothrombin index due to impaired
synthesis of clotting factors. Not restored by
vitamin K.
 Transient mild rise in alpha-foetoprotein during
regeneration phase
TOXIC HEPATITIS
 The liver is the site of metabolism of most drugs. Many
drugs are hepatotoxic. Some have idiosyncratic reactions,
others affect all individuals. Drugs may cause either:
 Toxic hepatitis (e.g. alcohol, paracetamol). Biochemical
changes similar to acute viral hepatitis.
INTRAHEPATIC CHOLESTASIS
 CAUSES:
• Drugs
• Benign recurrent intrahepatic cholestasis. Precipitated by
viral infections.
ALCOHOLIC LIVER DISEASE
 A range of liver pathology may occur in alcoholic liver disease,
ranging from fatty liver, to alcoholic hepatitis, to full blown
alcoholic cirrhosis.
 Biochemical features include:
• raised GGT because of induction as well as cholestasis
• mild disease - few additional biochemical indicators are present
• severe disease- transaminases are elevated, especially AST
(therefore the ALT/AST ratio is less than 1)
• in cirrhosis
 increased immunoglobulins esp. IgA
NON-ALCOHOLIC STEATOHEPATITIS (NASH)
 A form of chronic hepatitis which is similar histologically to
alcoholic hepatitis, but which occurs in non-alcoholic patients
 The pathogenesis is not yet known,
 Although the cause has not yet been definitively determined,
risk factors associated with the condition include:
• obesity
• Non insulin dependent diabetes mellitus (NIDDM)
• jejenal-ileal bypass
• small bowel resection and small bowel bacterial contamination
• drugs such as amiodarone, calcium channel blockers and others.

 Biochemical features include:

• raised transaminases, especially ALT
• hyperlipidaemia
• NIDDM
GALLSTONES
TYPES OF GALLSTONES:
Cholesterol stones.
The common gallstone. Predisposing factors are obesity, increasing age, female
sex, diabetes, hyperlipidaemia , chronic cholecystitis ,relative deficiency of tri- and
dihydroxy bile salts leading
 Oral chenodeoxycholic acid has been used therapeutically.

Pigment stones.
 Excess bilirubin production in haemolytic anaemias.

PRESENTATION:
 Intermittent passage of gallstone:
 Severe right upper quadrant abdominal pain (biliary colic).
 Intermittent jaundice and bilirubinuria.
 Intermittent elevations of ALP, GGT.
 Prolonged painless obstructive jaundice.
 Acute cholecystitis.
SPACE-OCCUPYING LESIONS OF THE LIVER

Causes:
 Primary liver cell carcinoma (hepatoma).
 Marked increase in alpha-foetoprotein.
 Predisposing factors:
 Cirrhosis.
 Previous hepatitis B infection.

Features:
 Enlarged firm liver.
 Increased ALP, GGT due to local obstruction
 However jaundice is rarely present and serum bilirubin is normal or
only slightly increased, since remaining normal tissue has large
reserve capacity for excreting bilirubin.
 AST, ALT normal/slightly increased.
NEONATAL JAUNDICE

 In utero, bilirubin is transported across the

placenta, conjugated and excreted by the
mother's liver. After birth the neonate must
excrete the bilirubin.
 Factors contributing to neonatal jaundice are
increased relative RBC mass, shorter RBC
lifespan, immature liver, especially in
premature neonates (takes 2-4 weeks to
develop fully).
Unconjugated Hyperbilirubinaemia:

Physiological Jaundice
 Jaundice develops on days 3-5 (never on day 1).
 Levels of bilirubin may reach 150 μmol/l, all unconjugated.
 Usually phototherapy is all the treatment that is required.
Non Physiological Jaundice
 Jaundice develops on day 1.
 Rhesus or ABO systems commonly responsible.
 A few foetal RBCs cross into maternal circulation, mother makes
antibodies if blood groups are incompatible. These IgGs then pass into
foetal circulation, causing haemolysis of foetal RBCs. Excessive bilirubin
production is not a problem for the foetus, since it crosses placenta and is
conjugated, excreted by mother's liver. However, bilirubin starts rising
rapidly after birth. Severe haemolysis in utero causes foetal anaemia and
heart failure ("hydrops foetalis").
 Inherited haemolytic disorders.
COMPLICATION

Risk of kernicterus when unconjugated bilirubin > 200

μmol/l. Risk is increased by other factors like
 Level of unconjugated bilirubin.
 Low albumin.
 Drugs (displace bilirubin from albumin).
 Acidosis (promotes dissociation of bilirubin from
albumin).
 Heparin administration (causes liberation of free fatty
acids which displace bilirubin from albumin).
 Hypoxia, hypoglycaemia, hypothermia, sepsis
(increase bilirubin transport into the brain).
TREATMENT

 Phototherapy - Light at 440-470 nm causes

formation in skin of isomers of unconjugated
bilirubin which are more soluble, excreted in
urine.
 Exchange transfusion required when bilirubin
> 305 μmol/l (term babies) or > 200 μmol/l in
premature babies or case of clinical features
of kirnecturus
Conjugated Hyperbilirubinaemia

TYPES
 Neonatal hepatitis : Many infective agents can cause
hepatitis in neonates (e.g. rubella, CMV, herpes simplex,
toxoplasmosis).
 Biliary atresia : Cause of biliary atresia is unclear: may be
toxic degeneration of bile duct rather than a congenital
malformation.
 Metabolic disorders like in inborn error of metabolism
explained above

TREATMENT
 - Treat the underlying condition.
 ASSIGNMENT
 1. The following results were obtained from a patient who presented to
medical outpatient clinic of Federal Teaching Hospital, Ido-Ekiti with
mild jaundice:

 Albumin 45g/l (35-50), total bilirubin 43μmol/l (<17), conj. bilirubin
2μmol/l (<4), Alk. Pho 102 U/l (39-117), LDH 720U/l (240-480), AST 72U/l
(1-38), ALT 25U/l(1-41)
 i) What type of disorder is indicated?
 ii) What biochemical abnormalities are likely to be present in this
patient's urine?
 iii) What LDH isoenzyme pattern would you expect to find?
 iv) What further investigations are required?
 v) List the causes of this type of disorder.

 2. A 63-year old man presented to surgical outpatient clinic of FTH,
Ido-Ekiti with haematemesis. He had lost 12 kg of weight over the
preceding 6 months. Gastroscopy showed a carcinoma of the
stomach. The following results were reported:

 urea 5.0 mmol/l (1.7-6.7) creatinine 66 μmol/l (60-115) total protein 55
g/l (60-80) albumin 23 g/l (35-50) calcium 1.86 mmol/l (2.1-2.6) total
bilirubin 15 μmol/l (<17) conj. bilirubin 3 μmol/l (<4) GGT 373 U/l (7-49)
 Alk. Phos. 443 U/l (39-117) LDH 344 U/l (240-480) AST 18 U/l (1-38) ALT
22 U/l (1-41)
 aFP 20 ng/ml (<10)
 i) What do the liver function tests indicate? Comment on the fact that
the bilirubin is not elevated.
 ii) Comment on the calcium level.