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16 Endocrine Testings: Suppression and Stimulation Tests

16 Endocrine Testings: Suppression and Stimulation Tests

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9.16 Endocrine Testings: Suppression and Stimulation Tests



Table 9.6 Common Endocrine Tests

Endocrine Test



Analytes Measured



Interpretation



Glucose tolerance test (GTT); for

hyperpituitarism.



Basal levels of FSH, LH, TSH, ACTH,

cortisol, GH, and then reanalysis of

these analytes after administration of

oral glucose.

Basal levels of FSH, LH, TSH,

prolactin, cortisol, GH, and reanalysis

of these analytes after administration

of insulin, GnRH, and TRH.

Basal cortisol at 8À9 AM and then

the next morning after receiving

dexamethasone.



With true hyperpituitarism basal levels

will be high and will not reduce.



Triple bolus (insulin, GnRH, TRH).



Overnight dexamethasone

suppression test (1 mg of

dexamethasone at bedtime); for

Cushing’s syndrome.

Low-dose dexamethasone test

(0.5 mg, q6h for 2 days); for

Cushing’s syndrome.

High-dose dexamethasone

suppression test (2 mg q6h for

2 days). Done after positive low

dose dexamethasone suppression

test to differentiate Cushing’s

disease from other causes.

Short ACTH (250 μg) stimulation

test for hypoadrenalism.

Long ACTH (1 mg) stimulation test

to differentiate primary from

secondary hypoadrenalism.



Basal cortisol level and reanalysis of

cortisol level after 48 hours.



With true hypopituitarism basal levels

will be low and will not rise.



Normal patients should have cortisol

below 5 μg/dL, but patients with

Cushing’s should not show any

suppression of morning cortisol level.

True Cushing’s syndrome patient will

have high levels and will not reduce.



Basal cortisol level and after

48 hours.



Cushing’s disease patient will show

50% or more reduction of cortisol

level; other causes of Cushing’s

syndrome will not.



Cortisol level before and after.



True hypoadrenalism patients will

have low basal levels and will not rise.

Patients with primary hypoadrenalism

will show no rise at all here as

patients with secondary

hypoadrenalism will show gradual

increase with time.



Cortisol level before and after (up to

24 hours).



pituitarism by measuring base levels of any of a combination of hormones,

including LH, FSH, ACTH, cortisol, and GH. Following oral administration of

glucose, values of these hormones should be suppressed, but with true hyperpituitarism, basal levels will be high and will not be suppressed following administration of oral glucose.

For diagnosis of hypopituitarism, especially dysfunction of the anterior pituitary, the bolus test (also known as the dynamic pituitary function test) is

used. In this test, three hormones, including insulin, gonadotropin-releasing

hormone (GnRH), and thyrotropin-releasing hormone (TRH), are injected in

a bolus into a patient’s vein to stimulate the anterior pituitary gland. Before

the bolus injection, baseline levels of cortisol, GH, prolactin, TSH, LH, and

FSH are measured. After bolus administration, insulin-induced hypoglycemia

should increase levels of cortisol and GH, while TRH should increase levels



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of TSH and prolactin, and levels of LH and FSH should increase due to

administration of GnRH. The serum glucose value is also measured to ensure

hypoglycemia induced by insulin. However, in a patient with hypopituitarism, levels of these hormones should stay low at baseline values despite

administration of these hormones by bolus injection.

Various dexamethasone suppression tests are useful in the diagnosis of

Cushing’s syndrome. Dexamethasone is a potent glucocorticoid that suppresses the nocturnal rise in ACTH levels and thus suppresses 8 AM cortisol

levels in a normal individual. In an overnight dexamethasone suppression

test, 1 mg of dexamethasone is given at bedtime and the serum cortisol level

at 8À9 AM is measured. In a normal individual the serum cortisol level

should be , 5 μg/dL following administration of dexamethasone; a value

over 5 μg/dL indicates Cushing’s syndrome. In a low-dose dexamethasone

suppression test, 0.5 mg of dexamethasone is administered every 6 h for two

days. The cortisol level is measured in the morning before and after administration of dexamethasone. In patients with Cushing’s syndrome, no suppression of the cortisol level is observed following administration of

dexamethasone. However, due to simplicity, a 1- mg dexamethasone suppression test is used more frequently. A high-dose dexamethasone suppression

test is useful to differentiate Cushing’s syndrome caused by adrenal tumors

and non-endocrine ACTH-secreting tumors from Cushing’s disease. This test

is usually performed after a low-dose dexamethasone suppression test or a

1-mg dexamethasone suppression test. In this test, 2 mg of dexamethasone

are administered every six hours for two days (an 8-mg total dosage), and

serum cortisol is measured in the morning before and after administration of

dexamethasone. In patients with Cushing’s syndrome, no suppression of the

morning cortisol level should be observed, but in patients with Cushing’s

disease, a 50% or more reduction of serum cortisol should be observed.

Although the glucose tolerance test is sometimes considered a gold standard

for evaluating hypothalamusÀpituitaryÀadrenal function in adrenal insufficiency, the ACTH stimulation test (also known as the cosyntropin test) is

also used to determine functional capacity of adrenal glands in evaluating

patients with suspected adrenal insufficiency. A normal individual should

show two- to three-fold increases in serum cortisol (a gradual increase with

time) within 1 h after administration of exogenous ACTH. In this test, after

administration of synthetic ACTH (tetracosactrin: 1À24 amino acid sequence

of human ACTH), if the serum cortisol level is not increased, it is indicative

of adrenal insufficiency. In the standard ACTH stimulation test (also known

as the short ACTH stimulation test), 250 μg of synthetic ACTH is administered intramuscularly or intravenously and a subnormal cortisol response

(,18 μg/dL; , 500 nmol/L) 30 to 60 min after the stimulation test is considered a positive test and indicates an increased possibility of primary or



Key Points



secondary adrenal insufficiency. A value over 20 μg/dL is considered a normal response. Sometimes a long-acting ACTH stimulation test using 1 mg of

synthetic ACTH is used for differentiation between primary and secondary

hypoadrenalism. More recently, a low-dose ACTH stimulation test using only

1 μg of synthetic ACTH has been introduced. This test is useful for the diagnosis of adrenal insufficiency; however, older males may have a more

decreased responsiveness to this test than older females [21]. Another alternative to test the function of the hypothalamusÀpituitaryÀadrenal axis is

administration of metyrapone, an inhibitor of 11 β-hydroxylase enzyme that

converts 11-deoxycortisol to cortisol. Under normal conditions, a reduced

cortisol level in plasma stimulates ACTH release and the concentration of

11-deoxycortisol in serum increases significantly; a lack of response suggests

primary adrenal failure.



KEY POINTS





















Endocrine activity can be classified as autocrine, paracrine, or classical endocrine

activity. In autocrine activity, chemicals produced by a cell act on the cell itself. In

paracrine activity chemicals produced by a cell act locally. However, in classical

endocrine activity, chemicals produced by an endocrine gland act at a distant site

after their release in the circulation; these chemicals are called hormones. Most

classical hormones are secreted into the systemic circulation. However,

hypothalamic hormones are secreted into the pituitary portal system.

Receptors for hormones may be cell surface, membrane, or nuclear receptors.

Hormone secretion may be continuous or intermittent. Thyroid hormone secretion

is continuous. Thus, levels may be measured at any time to assess hormonal

status. Secretion of follicle-stimulating hormone (FSH), luteinizing hormone (LH),

and growth hormone (GH) are pulsatile. Thus, a single measurement may not

reflect hormonal status. Some hormones exhibit biological rhythms. Cortisol

exhibits a circadian rhythm where levels are highest in the morning and lowest

during late night. The menstrual cycle is an example of a longer biological rhythm

where different levels of a hormone are observed during a specific part of the

cycle.

Certain hormone levels are elevated during stress. These include

adrenocorticotropic hormone (ACTH), as well as cortisol, GH, prolactin, adrenaline,

and noradrenaline.

Certain hormone levels are increased during sleep, such as GH and prolactin.

The hypothalamus produces thyrotropin-releasing hormone (TRH), corticotropin

hormone (CRH), gonadotropin-releasing hormone (GnRH), growth hormone-releasing

hormone (GHRH), and somatostatin (growth hormone inhibitory hormone). These

hormones act on the anterior pituitary and result in the release of various other

hormones, including thyroid-stimulating hormone (TSH), ACTH, FSH, LH, and GH.

Somatostatin inhibits the release of GH. Dopamine (also known as prolactin inhibitory



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hormone) is also a neurotransmitter produced by the hypothalamus. Dopamine can

inhibit GH secretion.

The supraoptic and paraventricular nuclei of the hypothalamus produce

antidiuretic hormone (ADH, i.e. vasopressin) and oxytocin. These hormones are

stored in the posterior pituitary and act on certain body parts rather than on the

pituitary like other tropic hormones do. ADH acts on the collecting ducts of the

renal tubules and causes absorption of water.

Growth hormone (GH, also known as somatotropin) is the most abundant hormone

produced by the anterior pituitary, and it stimulates growth of cartilage, bone, and

many soft tissues. GH stimulates release of insulin-like growth factor-1 (IGF-1,

somatomedin C), mostly from the liver.

Hyperpituitarism is most often due to pituitary tumors affecting GH-secreting

cells, prolactin-secreting cells, and ACTH-secreting cells. GH-secreting tumors

that affect individuals before closure of the epiphyses result in gigantism, and

after closure they result in acromegaly. Prolactin-secreting tumors cause

hyperprolactinemia. A high level of prolactin (prolactinemia) inhibits action of FSH

and LH, which results in hypogonadism and infertility. ACTH-secreting tumors

cause Cushing’s syndrome.

For diagnosis of hypopituitarism, stimulation tests with GnRH, TRH, and insulininduced hypoglycemia (a triple stimulation test) is useful. Following stimulation,

serum or plasma levels of FSH, LH, TSH, PRL, GH, and cortisol are measured.

Endocrine tests for hyperpituitarism include measurement of hormone levels and a

suppression test using glucose (oral glucose tolerance). Administration of glucose

with a rise in blood glucose should suppress anterior pituitary hormones in normal

individuals.

Four steps are involved in the synthesis of thyroid hormones: (1) inorganic iodide

from the circulating blood is trapped (iodide trapping), (2) iodide is oxidized to

iodine, (3) iodine is added to tyrosine to produce monoiodotyrosine and

diiodotyrosine (referred to as organification), and (4) one monoiodotyrosine is

coupled with one diiodotyrosine to yield T3 and two diiodotyrosines are coupled

to yield T4 (coupling).

Free (unbound) T4 is the primary secretory hormone from the thyroid gland. T4

is converted in peripheral tissue (liver, kidney, and muscle) to T3 by

5’-monodeiodination. T3 is the physiologically active hormone. T4 can also be

converted to reverse T3 by 3’-monodeiodination. This form of T3 is inactive. The

majority (99%) of the T3 and T4 in circulation is found to be thyroxine-binding

globulin (TBG), albumin, and thyroxine-binding prealbumin.

Dyshormonogenetic goiter may be associated with nerve deafness, referred to as

Pendred’s syndrome.

There are situations where thyroid hormone-binding proteins may be low or high,

causing alteration of total T3 and T4 levels. However, free T3, T4, and TSH levels

should be normal. Pregnancy and oral contraceptive pills raise concentrations of



Key Points











































thyroid-binding proteins. Hypoproteinemic states such as cirrhosis of the liver,

nephrotic syndrome, etc., may cause lower concentrations of thyroid-binding

proteins.

Amiodarone can reduce peripheral conversion of T4 to T3. Free T4 levels may be

high, but TSH levels could be normal. Because it contains an iodine molecule,

amiodarone can also cause both hypothyroidism and hyperthyroidism.

Seriously ill patients may have reduced production of TSH with low T4 and

reduced conversion of T4 to T3 with increased conversion of T4 to reverse T3.

Patients are, however, euthyroid. This is referred to as sick euthyroid syndrome.

Measurement of TSH can suffer interference from heterophilic antibody and

rheumatoid antibody, causing falsely elevated results. Rarely, autoantibodies to

TSH develop clinically, but such autoantibodies can also falsely increase TSH

results. A rare interference in the TSH assay is due to macro-TSH, an autoimmune

complex between anti-TSH IgG antibody and TSH.

Primary hypothyroidism (primary disease of thyroid gland): Causes include

autoimmune thyroiditis, Hashimoto’s thyroiditis, surgery/radiation,

dyshormonogenesis, antithyroid drugs, drug therapy with amiodarone, and

advanced age.

Secondary hypothyroidism can be due to lack of TSH from pituitary or peripheral

resistance to thyroid hormones.

Causes of hyperthyroidism include Graves’ disease, toxic nodular (single or

multiple) goiter, thyroiditis (e.g. due to viral infection), drugs, and excess TSH (e.g.

due to pituitary tumor).

Parathyroid hormone (PTH) is an 84-amino acid hormone secreted by the chief

cells of the parathyroid, and it increases calcium levels in blood by increasing

osteoclastic activity in bone, increasing synthesis of 1,25-dihydroxycholecalciferol

(vitamin D3), increasing renal reabsorption of calcium, as well as by increasing

intestinal absorption of calcium.

Calcitonin, which is secreted by the parafollicular C cells of the thyroid, essentially

has the opposite action to that of PTH.

Hyperparathyroidism is a common cause of hypercalcemia and can be primary

(due to adenomas or hyperplasia of parathyroid glands), secondary (due to

compensatory hypertrophy of parathyroid glands due to hypocalcemia, as seen in

chronic kidney disease), or tertiary (where after a long period of secondary

hyperparathyroidism the parathyroid glands develop autonomous hyperplasia and

hyperparathyroidism persists even when hypocalcemia is corrected).

Hypoparathyroidism refers to low levels of PTH being secreted from the

parathyroid glands, whereas pseudohypoparathyroidism refers to the inability of

PTH to exert its function due to a receptor defect. Pseudohypoparathyroidism

is a hereditary disorder, and patients, in addition to hypocalcemia, also have

short stature, short metacarpals, and intellectual impairment. Pseudopseudohypoparathyroidism patients actually have no abnormality of PTH or



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parathyroid. Only the somatic features seen in pseudohypoparathyroidism are

present, but these patients do not have cognitive impairment as seen in patients

with pseudohypoparathyroidism.

The adrenal glands consist of a cortex and a medulla. The cortex has three zones:

zona glomerulosa, zona fasciculata, and zona reticularis. The zona glomerulosa is

responsible for secreting mineralocorticoids (aldosterone), while the zona

fasciculata is responsible for secreting glucocorticoids. Finally, the zona reticularis

is responsible for producing sex steroids. The adrenal medulla produces

catecholamines.

Congenital adrenal hyperplasia is most often due to lack of 21-hydroxylase

enzyme causing decreased production of deoxycorticosterone and aldosterone,

as well as reduced levels of deoxycortisol and cortisol. ACTH level is also high,

and as a result, 17-hydroxypregnenolone and 17-hydroxyprogesterone are

produced in higher concentrations, which leads to increased production of

dehydroepiandrosterone, androstenedione, and testosterone. Female children

suffer a virilizing effect and may also have ambiguous genitalia. Male children

have features of precocious puberty.

Major causes of Cushing’s syndrome can be sub-classified under two broad

categories: (1) ACTH-dependent disorders, which include Cushing’s disease

(ACTH-secreting pituitary tumor), ectopic ACTH-producing tumor (such as lung

cancer), and secondary due to ACTH administration; and (2) non-ACTHdependent disorders (adrenal tumor or secondary due to glucocorticoid

administration). ACTH-dependent Cushing’s syndrome is more common (70À80%

of all cases) compared to non-ACTH-dependent disorders. Among ACTHdependent disorders, Cushing’s disease is observed more frequently.

Investigations that are useful for the diagnosis of Cushing’s syndrome include

measurement of 24-hour urinary free cortisol (values are elevated in Cushing’s

syndrome), loss of circadian rhythm (measurement of cortisol at 9 AM and

midnight should show loss of circadian rhythm as evidenced by higher midnight

cortisol values compared to 9 AM values in patients with Cushing’s syndrome), an

overnight dexamethasone suppression test (patients take 1 mg of dexamethasone

at bedtime and serum cortisol is measured the following morning; Cushing

syndrome patients should still show elevated levels of cortisol), as well as lowand high-dose dexamethasone suppression tests.

Pseudo-Cushing’s syndrome is caused by conditions such as alcoholism, severe

obesity, polycystic ovary syndrome, etc.; these can activate the

hypothalamicÀpituitaryÀadrenal axis and cause Cushing’s-like syndrome.

Conn’s syndrome is most often due to an adenoma secreting aldosterone from the

adrenal cortex. Clinical symptoms include hypertension (due to sodium and water

retention) and hypokalemia. Therefore, it is imperative to measure serum

electrolytes in a hypertensive patient if there is any suspicion of secondary

hypertension. Other tests that may be helpful for diagnosis of Conn’s syndrome



Key Points



























include aldosterone-to-renin ratio (ARR; increased in Conn’s syndrome), plasma

potassium and urinary potassium tests (in Conn’s syndrome hypokalemia in serum

and increased loss of potassium in urine is observed), and a saline suppression

test (aldosterone levels are measured before and after administration of normal

saline). Normal individuals should have lower aldosterone levels with the influx of

sodium, but in patients with Conn’s syndrome aldosterone levels may not change.

Renin levels are also low in Conn’s syndrome.

Adrenal insufficiency can be primary, secondary, or tertiary. Primary adrenal

insufficiency (hypoadrenalism) can be either acute or chronic. Primary acute

hypoadrenalism is most commonly due to hemorrhagic destruction of adrenal

glands (WaterhouseÀFriderichsen syndrome). Chronic hypoadrenalism is

Addison’s disease, where there is progressive dysfunction of adrenal glands a local

disease process or systematic disorder. Secondary hypoadrenalism is due to lack

of ACTH from the pituitary because of hypothalamusÀpituitary dysfunction.

Tertiary hypoadrenalism is due to lack of corticotropin-releasing hormone (CRH).

Causes of Addison’s disease include congenital adrenal hyperplasia due to

enzyme defect, autoimmune disease, post-surgery complications, tuberculosis,

and sarcoidosis.

Hypogonadism may be broadly divided into two categories: hypergonadotropic

and hypogonadotropic hypogonadism. Examples of hypergonadotropic

hypogonadism include gonadal agenesis, gonadal dysgenesis (e.g. Turner’s

syndrome and Klinefelter’s syndrome), steroidogenesis defect, gonadal failure

(e.g. mumps, radiation, chemotherapy, autoimmune diseases, granulomatous

diseases), and chronic diseases (e.g. liver failure, renal failure).

Examples of hypogonadotropic hypogonadism include hypothalamic lesions (e.g.

tumors, infections, Kallmann’s syndrome) and pituitary lesions (e.g. adenomas,

Sheehan’s syndrome, sarcoidosis, hemochromatosis).

Gastrinomas cause increased secretion of gastric acid, which results in multiple

recurrent duodenal ulcers (ZollingerÀEllison syndrome). VIPomas produce

excessive vasoactive intestinal polypeptides (VIP) that cause watery diarrhea

(VernerÀMorrison syndrome). Glucagonomas are rare tumors from the alpha islet

cells. Features include diabetes mellitus, migratory necrolytic dermatitis, and deep

vein thrombosis. Somatostatinomas are rare tumors derived from the delta islet

cells. Features include diabetes mellitus and gallstones. This condition is caused

by the occurrence of simultaneous or metachronous tumors that involve multiple

endocrine glands. The subtypes are MEN type 1 (parathyroid adenoma or

hyperplasia with pituitary adenoma and pancreatic islet cell tumor), MEN type 2a

(adrenal tumor with medullary carcinoma of thyroid and parathyroid hyperplasia),

and MEN type 2b (type 2a with marfanoid habitus, intestinal, and visceral

ganglioneuromas).

Glucose tolerance test is useful in the diagnosis of hyperpituitarism.



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For diagnosis of hypopituitarism, a bolus test (also known as dynamic pituitary

function test) is used where three hormones, including insulin, GnRH, and TRH

are injected as a bolus into a patient’s vein to stimulate the anterior pituitary

gland. Before bolus injection, baseline levels of cortisol, GH, prolactin, TSH, LH,

and FSH are measured. After bolus administration, insulin-induced hypoglycemia

should increase levels of cortisol and GH, while TRH should increase levels of TSH

and prolactin; finally, levels of LH and FSH should be increased due to

administration of GnRH. Serum glucose value is also measured to ensure

hypoglycemia induced by insulin. In a patient with hypopituitarism, levels of these

hormones should stay low at baseline values despite administration of these

hormones by bolus injection.

In patients with Cushing’s syndrome, no suppression of cortisol level is observed

following administration of dexamethasone.

High-dose dexamethasone suppression test is useful to differentiate Cushing’s

syndrome caused by adrenal tumors and non-endocrine ACTH-secreting tumors

from Cushing’s disease.

Although the glucose tolerance test is sometimes considered the gold standard for

evaluating hypothalamusÀpituitaryÀadrenal function in adrenal insufficiency, the

ACTH-stimulation test (i.e. the cosyntropin test) is also used to evaluate the

functional capacity of adrenal glands in a patient with suspected adrenal

insufficiency. Sometimes the long-acting ACTH-stimulation test using 1 mg of

synthetic ACTH is used for differentiation between primary and secondary

hypoadrenalism. In primary hypoadrenalism there will be no rise in serum cortisol.

However, in secondary hypoadrenalism there will be a gradual increase in serum

cortisol.



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2013;4:13À24.

[2] Lee HJ, Macbeth AH, Pagani J, Young 3rd WS. Oxytocin: the great facilitator of life. Prog

Neurobiol 2009;88:127À51.

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[4] Todd CH. Management of thyroid disorders in primary care challenges and controversies.

Postgrad Med J 2009;85:655À9.

[5] Loh TP, Kao SL, Halsall DJ, Toh SA, et al. Macro-thyrotropin: a case report and review of literature. J Clin Endocrinol Metab 2012;97:1823À8.

[6] Dufour DR. Laboratory tests of thyroid function: use and limitations. Endocrinol Metab Clin

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[7] Zaletel K, Gaberscek S. Hashimoto’s thyroidititis: from genes to the disease. Curr Genomics

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[8] Gaitonde D, Rowley K, Sweeney LB. Hypothyroidism: an update. Am Fam Physician

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of Graves’ disease and variants in genes involved in immune response. PLoS One 2013;8

(3):e59349.

[10] Reid JR, Wheeler SF. Hyperthyroidism: diagnosis and treatment. Am Fam Physician

2005;72:623À30.

[11] Hamasaki H, Yoshimi T, Yanai H. A patient with Graves’ disease showing only psychiatric

symptoms and negativity for both TSH receptor autoantibody and thyroid stimulating antibody. Thyroid Res 2012;5:19.

[12] Ravikumar D, Lin M. A 37 year old woman with altered mental status and urinary frequency. West J Emerg Med 2013;14:177À9.

[13] Mouallem M, Shaharabany M, Weintrob N, Shalitin S, et al. Cognitive impairment is prevalent in pseudohypoparathyroidism type Ia, but not in pseudopseudohypoparathyroidism:

possible cerebral imprinting of Gsalpha. Clin Endocrinol (Oxf) 2008;68:233À9.

[14] Vilar L, Freitas Mda C, Faria M, Montenegro R, et al. Pitfalls in the diagnosis of Cushing’s

syndrome. Arq Bras Endocrinol Metabol 2007;51:1207À16.

[15] Besemer F, Pireira AM, Smit JW. Alcohol induced Cushing syndrome: hypercortisolism

cause by alcohol abuse. Neth J Med 2011;69:318À23.

[16] Mise K, Ubara Y, Sumida K, Hiramatsu R, et al. Cushing’s syndrome after hemodialysis for

21 years. J Clin Endocrinol Metab 2013;98:13À9.

[17] Mitchell AL, Pearce SH. Autoimmune Addison’s disease: pathophysiology and genetic complexity. Nat Rev Endocrinol 2012;8:306À16.

[18] Ferreira F, Martins JM, do Vale S, Esteves R, et al. Rare and severe complications of congenital adrenal hyperplasia due to 21 hydroxylase deficiency: a case report. J Med Case Rep

2013;6:39.

[19] Teede H, Deeks A, Moran L. Polycystic ovary syndrome: a complex condition with psychological, reproductive and metabolic manifestations that impacts on health across the life

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[20] Kim EU, Oh MC, Lee EJ, Kim SH. Predicting long term remission by measuring immediate

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[21] Lekkakou L, Tzanela M, Lymberi M, Consoulas C, et al. Effects of gender and age on

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[e-pub ahead of print].



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CHAPTER 10



Liver Diseases and Liver Function Tests



10.1 LIVER PHYSIOLOGY

The liver is the largest internal organ of the body, approximately 1.2 to 1.5 kg

in weight. The liver performs multiple functions essential to sustaining life

and is the principal site for synthesis of all circulating proteins, except gamma

globulins. A functioning normal liver produces 10À12 g of albumin daily; the

half-life of albumin is approximately 3 weeks. When liver function is impaired

over a prolonged period, albumin synthesis is severely impaired.

Hypoalbuminemia is commonly found in chronic liver disease. However, a

significant reduction in serum albumin levels may not be observed in patients

with acute liver failure. In addition to albumin, all clotting factors (with the

exception of Factor VIII) are produced in the liver. Therefore, as expected

when liver function is significantly impaired, there is reduced production of

clotting factors by the liver. As a result, coagulation tests such as prothrombin

time (PT) is prolonged. Liver is also the site of urea production. In severe liver

disease, such as fulminant hepatic failure, urea levels may be low. The liver

also stores about 80 g of glycogen. Liver releases glucose into the circulation

by glycogenolysis and gluconeogenesis. Again, in severe liver disease, hypoglycemia may be apparent due to depletion of the glycogen supply. Therefore,

common features of significant liver dysfunction include:







Prolonged PT, low serum glucose, and urea.

Severe hypoalbuminemia, a common feature of chronic liver disease.



The liver also plays a major role in the synthesis of various lipoproteins, including very low density lipoprotein (VLDL) and high density lipoprotein (HDL).

Hepatic lipase removes triglycerides from intermediate density lipoprotein

(IDL) to produce low density lipoprotein (LDL). Liver is also a site for cholesterol synthesis. Cholesterol is esterified with fatty acids by the action of enzyme

lecithin cholesterol acyl transferase (LCAT). In liver disease LCAT activity may

be reduced, resulting in an increased ratio of cholesterol to cholesteryl ester.



CONTENTS

10.1 Liver

Physiology................ 177

10.2 Liver Function

Tests and

Interpretations......... 179

10.3 Jaundice: An

Introduction ............. 182

10.4 Congenital

Hyperbilirubinemia . 182

10.5 Hemolytic

(Prehepatic)

Jaundice ................... 184

10.6 Hepatocellular

Jaundice ................... 185

10.7 Chronic Liver

Disease ..................... 185

10.8 Cholestatic

Jaundice ................... 187

10.9 Alcohol- and

Drug-Induced Liver

Disease ..................... 188

10.10 Liver Disease

in Pregnancy............ 188

10.11 Liver Disease in

Neonates and

Children.................... 189

10.12 Macro Liver

Enzymes................... 190



177

A. Dasgupta and A. Wahed: Clinical Chemistry, Immunology and Laboratory Quality Control

DOI: http://dx.doi.org/10.1016/B978-0-12-407821-5.00010-3

© 2014 Elsevier Inc. All rights reserved.



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L i v er D i s e a s e s an d L i v e r Fu n c t i o n T e s t s



10.13 Laboratory

Measurement of

Bilirubin and Other

Tests ......................... 190

Key Points ................ 191

References ............... 195



This may alter membrane structure with formation of target cells, as seen in liver

disease. Bile acids are also synthesized in the liver from cholesterol and are

excreted as bile salts. The primary bile acids (cholic acid and chenodeoxycholic

acid) are converted into secondary bile acids by bacterial enzymes in the intestine. The secondary bile acids are deoxycholic and lithocholic acid. In liver diseases decreased production of bile acids may result in fat malabsorption.

Liver is the site of bilirubin metabolism. Heme, derived from the breakdown

of hemoglobin, is converted to biliverdin and finally into bilirubin, which is

water-soluble, unconjugated bilirubin. Unconjugated bilirubin can also bind

with serum proteins, most commonly albumin. Unconjugated bilirubin is

taken up by the liver, and, with the help of the enzyme UDP (uridine-50 diphosphate) glucuronyl transferase, is converted to conjugated bilirubin

(bilirubin conjugated with glucuronide). This conjugation takes place in the

smooth endoplasmic reticulum of the hepatocyte. Conjugated bilirubin is

water-soluble and is excreted in bile. In the clinical laboratory, conjugated

bilirubin is measured as direct bilirubin, while subtracting total bilirubin

from the direct bilirubin value provides the concentration of unconjugated

bilirubin (also referred to as indirect bilirubin). In the intestine, bacterial

enzymes hydrolyze conjugated bilirubin and release free bilirubin, which is

reduced to urobilinogen. Urobilinogen bound to albumin is excreted in the

urine. Some urobilinogen is converted to stercobilinogen in the intestine and

is excreted in stool. Thus, in normal urine, only urobilinogen is present and

in normal stool stercobilinogen is present. In obstructive (cholestatic) jaundice conjugated bilirubin regurgitates into the blood, and, because it is

water-soluble, it is excreted into the urine. This is called choluria, or the presence of bile in urine. In obstructive jaundice, less conjugated bilirubin is

taken by the intestine and as a result less stercobilinogen is found in the

stool (pale stools). Normal individuals have mostly unconjugated bilirubin

in their blood, urobilinogen in their urine, and stercobilinogen in their stool.

The distribution of bilirubin, urobilinogen, and stercobilinogen in various

diseases are summarized below:













In individuals with hemolytic anemia, the excess breakdown of

hemoglobin causes unconjugated hyperbilirubinemia. Urobilinogen in

urine and stercobilinogen in stool may also be increased.

In hepatocellular jaundice, uptake and conversion of unconjugated

bilirubin into conjugated bilirubin is also reduced, resulting in

unconjugated hyperbilirubinemia. However, amounts of urobilinogen in

urine and stercobilinogen in stool are not increased.

In cholestatic jaundice, conjugated hyperbilirubinemia is usually

observed. Because conjugated bilirubin is water-soluble, it is excreted in

urine (choluria). However, urobilinogen and stercobilinogen quantities

are reduced.



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16 Endocrine Testings: Suppression and Stimulation Tests

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