Bile function test

Late adverse effects include hepatic dysfunction, with altered liver function tests and hyperbilirubinemia. After prolonged use of nicotinic acid and nicotinyl alcohol, histological changes, for example parenchymal cell injury, portal fibrosis, cholangitis, cholestasis, biliary casts, and lymphocytic infiltrations around the bile ducts, have occasionally been seen. 

After the introduction of modem biochemical techniques (such as enzyme diagnostics, serology and immunology) into hepatology, only a few of the numerous hver function tests have prevailed. Hepatic diagnostics has been streamlined and completely redeveloped. Only the determination of bilirubin, serum iron and urinary bile pigments has remained from the first epoch. 

Indocyanine green was introduced by J. Caesar et al. in 1961 as a liver function test. Anionic tricarbocyanine dye is referred to as an ideal test substance (1.) it is tolerated very well there have been no reports of any incidents so far, and even paravenous injection is tolerated (2.) it is excreted unchanged by hepatocytes in the bile as there is no bio transformation - this is why ICG clearance is valid as a measure of hepatocellular uptake and transport processes (3.) there is no interference with drugs (except rifamycin), haemolysis, bilirubin (up to approx. 4 mg/dl) or hyperlipidaemia (4.) the substance is not subject to the enterohepatic circulation (J.) the rapid elimination, which depends on hepatic perfusion ( flow-limited ), allows the calculation of the hepatic flow volume as a whole based on ICG clearance (6.) the method is simple to perform. 

A 65-year-old man presented with severe abdominal pain 90 minutes after taking codeine and low-dose paracetamol. Serum amylase and lipase were significantly raised. Liver function tests were moderately abnormal. Abdominal ultrasound and CT scan showed edematous pancreatitis. Endoscopic retrograde cholangiography showed a papilla with a spastic appearance and an abnormal bile duct. He recovered completely, but 3 months later took codeine and paracetamol after a hemorrhoidectomy abdominal pain recurred 1 hour later and acute pancreatitis was confirmed. 

Parenchjmal hver damage can occur in patients taking tiabendazole and abnormal liver function tests have been documented (9). There have been well-studied cases of bile duct injury, which can lead to micronodular cirrhosis (10), and a case in which these various forms of liver disorder co-existed and hver transplantation proved necessary (11). 

Increased plasma bile acid concentrations in the fasting state suggest impaired hepatic uptake or secretion, or portosystemic shunting. Thus, such measurements may be used as a sensitive endogenous clearance test. However, a diagnosis suggested by an increase in plasma bile acid concentrations should be confirmed by standard liver function tests. In a similar manner, abnormal standard liver function tests can be confirmed as indicative of hepatic dysfunction by concomitant measurement of plasma bile acids. Plasma bile acid measurements may also be used serially to monitor patients with suspected or proven hepatic disease. However, they add little to standard tests of hver function and are now rarely used in clinical medicine. 

Although research has shown that bile acids play an important role in liver and intestinal function, and that the metabolism or enterohepatic circulation of bile acids is altered in certain diseases, tests involving bile acids are uncommon in the clinical chemistry laboratory. This is probably because bile acid tests are not absolutely necessary for the diagnosis of any important or well-known disease and they are generally regarded as too specialized for routine use (H12). Thus, at present bile acid tests tend to be confined to gastroenterology units with research interests in bile acid metabolism. However, there is currently much interest in evaluating serum bile acid levels as a liver function test (H19) and bile acid tests have been developed to assess various aspects of intestinal function, as described below. 

It is still too early to tell whether serum bile acid determinations will be added to the currently available combination of liver function tests or replace individual tests, such as the measurement of bilirubin (H19). In correctly diagnosing patients with histologically defined liver disease, serum bile acids appear to slightly improve the results from conventional liver tests, if used in combination with these tests (F3). Perhaps when sensitive analytical methods such as bioluminescence, which can be applied to serum bile acid analysis, become available and established in diagnostic laboratories, serious consideration will be given to routine measurement of serum bile acid levels to... 

COMPAWSON OF THE SeNSITIVITV OF PASTING SeRUM BiLE ACID LeVEI-S WITH ThaT OF Routine Liver Function Tests in the Diagnosis of Histologically Classified... 

F2. Ferraris, R., Colombatti, G., Fiorentini, M. T., Carosso, R., Arossa, W., and de la Pierre, M., Diagnostic value of serum bile acids and routine liver function tests in hepatobiliary diseases. Dig. Dis. Sci. 28, 129-136 (1983). 

James, O., Lesna, M., Roberts, S. H., Pulman, L, Douglas, A. P., Smith, P. A., and Watson, A. J., Liver damage after paracetamol overdose Comparison of liver function tests, fasting serum bile acids and liver histology. Lancet 2, 579-581 (1975). 

Meyer, D. J. 1986. Liver function tests in dogs with portosystemic shunts Measurement of serum bile acid concentraton. Journal of the American Veterinary Medical Association 188 168-169. 

Only one individual demonstrated hepatomegaly and bile in the urine, although another patient also demonstrated mildly elevated liver function tests. (The liver function tests on this last patient remained elevated for years, but it is unclear whether this is actually a sequela of this illness. In addition, this individual had previous exposures to staphylococcal enterotoxins while working at a different laboratory.) No diarrhea was reported in any of the exposed individuals. 

Biliary tract Vanishing bile duct syndrome occurred in a 60-year-old woman after she had taken meropenem for 3 weeks meropenem was withdrawn and after several months her liver function tests improved [6 ]. 

The bromosulphalein (BSP) test, i. e., the elimination of disodium phenoltetrabromophthalein-sulphonate from plasma by the liver, is in general use as a liver function test. According to Whelan and Plaa [189], the metabolites of BSP, produced during its passage through the liver parenchjuna and detectable in the bile, plasma, lymph and urine, can be separated and quantitatively determined by TLC cellulose thin layers and the solvent butanol-acetic acid-water (40 + 10 + 50) (upper phase) are used. 

When duodenal obstruction occurs without jaundice and a biliary stent is not in situ, subclini-cal biliary obstruction must be excluded before duodenal stent placement. Careful assessment of the biliary system is important so that impending bile duct obstruction can be treated. Where ERCP is precluded by the duodenal tumour, information from CT may be complemented by ultrasound or magnetic resonance cholangio-pancreatography (MRCP). If the patient s liver function tests are abnormal in the absence of hepatic metastases, this should be assumed to reflect biliary obstruction and a biliary stent placed. It is wise to place a metal biliary stent first, either endoscopically or transhepati-cally before placing a duodenal stent. 

Fig. 4.2. 25. Bile duct anastomotic stricture. A 37-year-old female status post fulminant acute hepatitis A, followed by orthotopic cadaveric liver transplant presenting now with abnormal liver function tests. Coronal thick-slab T2-weighted single-shot fast spin echo (SSFSE) MRCP image shows a short-segment stenosis (arrow) at the biliary anastomosis with upstream dilatation of the common bile duct. The remnant of the cystic duct (arrowhead) and a small amount of hyperintense fluid in the duodenal lumen (asterisk) are also seen...

---