GIT Dr. Shaf3y

P a g e | 1

G.I.T.

27

122013

artificial lung ventilator

artificial heart heart lung machine

artificial liver

artificial liver

artificial liver

2

Liver

Liver 2

Which is impossibleartificial liver

Liver artificial liver

Liver

Liver

Liver

liver << carbohydrates metabolism

Liver carbohydrates

GIT Dr. Shaf3y

P a g e | 2

glycogen Liver glucose Normal level

glycogen

Which meansLiver Normal

glycogenesis

glycogen

glycogenolysis

gluconeogenesis

glucose amino acids

glucose << Normal

Liver metabolism of protein

Liver Proteins

globulins

immune globulins

Liver albumin

alpha one globulin

beta globulins

transferrin

trans cobalamine 2

proteins immune globulins

Immune globulins

Reticuloendothelial system

Immune system

Immune globulins antibodies

GIT Dr. Shaf3y

P a g e | 3

Liver

exclusive proteins

albumins << exclusively Liver

Liver

Liver

liver break down

Proteins Ammonia

ammonia Liver

Urea

urea

Kidney urea

urine

Liver proteins

proteins

proteins ammonia

ammonia Liver Urea

Kidney urea

liver Metabolism of Fat

liver Metabolism of fat

cholesterol

cholesterol

Diet Liver

Diet intestine

blood stream

cholesterol Diet Non estratified cholesterol

Non estratified cholesterol

GIT Dr. Shaf3y

P a g e | 4

Diet

non estratified

wall blood vessel atherosclerosis

Diet

blood vessel

atherosclerosis

cholesterol Liver

cholesterol Liver

Liver

Liver

Liver Estratrified cholesterol

blood vessel

atherosclerosis

diet Liver

diet

Liver

Liver cholesterol

Liver cholesterol

non estratified cholesterol Diet Liver

Low density

non Estratified

diet

High density

liver blood vessel

GIT Dr. Shaf3y

P a g e | 5

Liver

low density lipoprotein Liver

Liver level

cholesterol level Normal

cholesterol << totally Normal

Non estratified bad good

bad non Estratified

Liver cell failure

atherosclerosis

thrombosis

coagulation factors

atherosclerosis

thrombosis

coagulation factors

clotting factor thrombus

vitamins

liver vitamins

Vitamin Kliver activation

Liver activation vitamin D

liver folic acid B12

Liver << Suicidal

activation vitamin K

activation vitamin D

storage folic acid and B12

GIT Dr. Shaf3y

P a g e | 6

Minerals

Liver minerals

storage iron

metabolism

liver functions Metabolism

DetoxicationDetoxification

Detoxification

toxins liver

toxins drugs drugs Liver toxins ammonia Liver ammonia urea

Kidney

Detoxification

function Liver

Coagulationcoagulation factors

1972

2,, 7,, 9,, 10

Liver anti coagulant

Protein C and protein S

coagulation factors

anti coagulant protein C and protein S

bile

Liver bile

Liver 600 bile

300 gall bladder 300intestine<< directly

bile fat absorption

Immunological

GIT Dr. Shaf3y

P a g e | 7

G.I.T. Portal vein

G.I.T. Portal vein

directly

sepsis

HCL HCL

intestine

absorption

Portal blood Liver

Liver Von Kupffer cell

Von Kupffer cell

macrophages

Portal blood

Liver

phagocytosis

Liver

Liver

Macrophages activated Liver Von Kupffer cell

activate Other immune system

cytokines activate T. Lymphocytes B. Lymphocytes

portal vein

Liver

macrophages Von Kupffer

Cytokines activate immune system

GIT Dr. Shaf3y

P a g e | 8

functions Liver

Endocrinal

liver erythropoietin

20 %erythropoietin

Liver activate << vitamin D

growth hormoneLiver

Liver somatomediens Insulin like growth factor

growth hormone direct

Liver somatomedines C

Liver

growth hormone

function

anatomy of the liver

Liver function

Liver Function liver function

Liver functions

testing function of the liver

testing

testfunction of the liver

enzymes

GIT Dr. Shaf3y

P a g e | 9

Enzymes

function of the liver

enzymes damage of the liver

function of liver

enzymes enzymes

ASTSGOT

Serum Glutamic Oxaloacetic transaminases

AST

Liver heart Kidney lung RBCs Muscles intestine placenta

Organs damage

diagnostic Liver disease

enzymeliver damage

Liver damage

liver improve

as a prognostic marker

as a prognostic marker

AST SGOT

ALT SGPT Serum Glutamic Pyruvic transminases

ALT SGPT

Liver G.I.T.

Liver G.I.T.

<< More specific for the liver

Liver disease

SGOT SGPT

GIT Dr. Shaf3y

P a g e | 10

SGPT

Liver

follow up SGOT

SGPT

SGPT SGOT

Liver

Liver

follow up

SGOTSGPT

Alkaline phophatasealkaline phosphatase Liver bone

alkaline phophatase Liver bone

Liver bone

symptoms

SGOT SGPT Liver

bone

alkaline phosphatase SGOT SGPT

Liver

SGOT SGPT bone

alkaline phosphatase Liver SGPT

GIT Dr. Shaf3y

P a g e | 11

alkaline phosphatase

liver disease

Liver disease

Liver disease

Normal level << alkaline phosphatase

313k A unit

Normal level of alkaline phosphatase

313

level

1330

cirrhosis Hepatitis

cirrhosis Hepatitis

30

Obstructive jaundice hepatocellular carcinoma

unit alkaline phosphatase

KA Unit

unit

313unit

international unit

international unit

30130

130300

Cirrhosis Hepatitis

300

obstructive jaundice hepatocellular carcinoma

GIT Dr. Shaf3y

P a g e | 12

alkaline phosphatase

Liver disease

Liver disease

alkaline phosphatase

bone disease

bone disease alkaline phosphatase

bone disease osteomyelitis, fracture, osteosarcoma, metastasis, Paget disease of the bone, hyper parathyroidism

disease bone

alkaline phosphatase

enzyme 5 Nucleotidase

target

5 Nucleotidase

alkaline phosphatase

Liver bone

5 Nucleotidase

liver disease

bone disease

alkaline phophatase

liver bone

SGOT SGPT

bone Liver

5 Nucleotidase

Gamma G.T.Gamma glutamyle transferase

GIT Dr. Shaf3y

P a g e | 13

Gamma Glutamyle Transferase

Gamma Glutamyle Transferase

ESR of the liver

ESR of the liver

ESR infection inflammation

ESR infection inflammation

Gamma G.T. liver disease

Gamma Glutamyle Transferase

liver disease

liver disease Gamma G.T.

Follow upFollow up<< go home

SGOT

Gamma G.T.

enzyme Hepatotoxic drugs

Hepatotoxic drugs

Gamma G.T.

hepato-toxic drug Alcohol

Alcohol gamma G.T.

Gamma G.T.

follow up absence from alcoholism

GIT Dr. Shaf3y

P a g e | 14

Gamma G.T.

Gamma G.T.

Hepatotoxic drug

alcoholism

rejection

rejection

rejection

Gamma G.T.

obstructive jaundice

obstructive jaundice

Gamma G.T.

enzymes

Liver disease

enzymes at least 3

SGOT normal 40

SGOT 55

Liver disease

Liver enzymes 3

fatty liver

Normal 67 75 diabetic

GIT Dr. Shaf3y

P a g e | 15

Obese

15

4055

15

hepatitis marker Liver biopsy

fatty liver

enzymes

enzymes Liver damage

enzymes Liver

enzymes Liver exhausted

fulminant hepatic failure extensive damage Liver

enzymes

SGOT 3,000

900

400

Liver

Liver

enzymes

bilirubin

bilirubin enzymes << liver

bilirubin enzymes <<Liver

1

GIT Dr. Shaf3y

P a g e | 16

investigations

how to interpret data

data

enzymes investigations Liver

Bilirubin

Heme and globin

haem

Iron Protoporphyrin

Protoporphyrin bileverdine bileverdine indirect bilirubin

Indirect bilirubin Liver

direct bilirubin

direct bilirubin bile

Intestine stercobilinogen

stercobilinogen

Liver

Entero-hepatic circulation

urine

urobilinogen

jaundice

Hemolytic Obstructive Hepatocellular

GIT Dr. Shaf3y

P a g e | 17

Hemolytic

Hemolytic

hemoglobin

heme

bileverdine

indirect bilirubin

Indirect bilirubin

indirect bilirubin

direct bilirubin liver

indirect

direct liver

direct bile intestine

stercobilinogen

stercobilinogen

stool dark

urobilinogen

urine dark on standing

Dark on standing

Urine << dark on standing

whatever

Normal color

GIT Dr. Shaf3y

P a g e | 18

urobilin Oxidation

dark on standing

stercobilinogen dark stool

urobilinogen urine << dark on standing

Obstructive jaundice

obstruction

Hemoglobin Normal

heme Normal

bileverdine Normal

indirect bilirubin Normal

direct bilirubin Normal

Obstruction

direct bilirubin

direct bilirubin << is water soluble

dark urine

dark urine

Obstructive jaundice

direct bilirubin

direct bilirubin

bile salts

GIT Dr. Shaf3y

P a g e | 19

bile salts bradycardia puritis frothy urine

frothy urine

obstructive jaundice

hemoglobin

heme

bileverdine

indirect bilirubin

direct bilirubin

direct bilirubin

direct bilirubin

bile salts

bradycardia puritis

direct bilirubin

dark urine frothy

stercobilinogen

stool clay

urobilinogen

urine << dark

Darkdirect bilirubin

Hepatocellular

hepatocellular jaundice

hemoglobin << Normal

heme << normal

bileverdine << normal

indirect bilirubin <<Normal

Liver disease

GIT Dr. Shaf3y

P a g e | 20

Indirect bilirubin

Indirect

indirect Liver

direct bilirubin

Liver cells

Indirect bilirubin hepatocyte

direct bilirubin

Liver disease

direct

Liver disease Hepatocellular jaundice Liver indirect

Indirect

Liver direct

Liver direct

direct

hepatocellular

indirect direct

stercobilinogen

direct bilirubin

Urobilinogen

variant

stercobilinogen

stercobilinogen

urobilinogen

GIT Dr. Shaf3y

P a g e | 21

hepatocellular

disease Liver

indirect bilirubin direct bilirubin

stool stercobilinogen

Urobilinogen

direct bilirubin intestine

stercobilinogen

stercobilinogen

Liver urobilinogen

Liver disease

stercobilinogen

Liver

Liver

stercobilinogen

Urobilinogen Urine

normal

Liver urine

Liver disease

stercobilinogen

GIT Dr. Shaf3y

P a g e | 22

Liver

entero-hepatic circulation

Liver

urobilinogen << variable

Liver

direct bilirubin

direct bilirubin Urine

GIT Dr. Shaf3y

P a g e | 23

Mother of bilirubin

father of the enzymes

mother of proteins

protein

coagulation profile Liver cell failure

Coagulation profile

Liver

coagulations factors

1972

27910

PT PTT

Factors << 1972

27910

pathways extrinsic intrinsic

PT PTT

pathways

GIT Dr. Shaf3y

P a g e | 24

PT

PT

prothrombin time extrinsic pathway

extrinsic pathway factor << 3 + 7

factor 7Liver

6

liver

Liver cell failure

PT PTT

PT

PT

liver

factor 7prothrombin time

half life 6 hours

Half life 6 hours

coagulation

proteins

Protein

albumin

Protein total protein

Albumin Globulin

GIT Dr. Shaf3y

P a g e | 25

Normal levels

6

868

Normal levels

Normal ratio albumin globulin

4 / 2

4 /2

ratio

albumin

half life 21

albumin half life 21

Which meansHepatitis albumin

Normal

albumin

at least << 3 weeks

at least<< 3 weeks

albumin acute liver disease

chronic liver disease

liver enzymes

hepatitis

cirrhosis

enzymes

GIT Dr. Shaf3y

P a g e | 26

Hepatitis cirrhosis

albumin

albumin <<chronic << cirrhosis

albumin <<Normal << acute << hepatitis

albumin

acute chronic

albumin

chronic

globulins

globulins

globulins

alpha globulins alpha alpha one alpha two

beta globulins gamma globulins

alpha one globulins

alpha one antitrypsin

COPD

congenital emphysema

alpha one antitrypsin

alpha one antitrypsin deficiency

alpha two globulin beta globulin

alpha two beta

Liver bile

bile

alpha two beta

GIT Dr. Shaf3y

P a g e | 27

obstructive jaundice

obstructive jaundice

This is for theoretical interest not for clinical application

already obstructive jaundice

alkaline phosphatase

theoretical

gamma globulins

antibodies

gamma globulins

antibodies

gamma globulins acute chronic liver disease

acute Hepatitis B or C

antibodies

Hepatitis markers

acute liver disease

immune globulins

chronic

liver

Portal vein Liver

Liver

GIT Dr. Shaf3y

P a g e | 28

bacteremia

bacteremia activate Immune system

immune globulins

chronic liver disease Liver cirrhosis

Liver

Liver

liver

bacteremia

Immune globulins

Immune globulins antibodies

acute and chronic liver disease

acute chronic liver disease

gamma globulins

acute chronic liver disease

gamma globulins

acute chronic liver disease

Immune globulins

liver disease

Liver disease

immune globulin E

alcoholic liver disease

Immune globulin G

chronic hepatitis

GIT Dr. Shaf3y

P a g e | 29

Immune globulin M

Primary biliary cirrhosis

Ammonia

liver cell failure

Ammonia

ammonia liver Urea

Liver

ammonia

ammonia toxins

ammonia toxins

test detoxication test

toxins

Liver

toxins

Liver toxins

Liver

<<test << Bromosulphthalein (BSP) test test

obsolete

serum ammonia

clearance test

clearance test

Local anaethesia anti arrhythmia anti epileptic

GIT Dr. Shaf3y

P a g e | 30

Liver

Saysay

Liver

clearance test

worse patient

time

GIT Dr. Shaf3y

P a g e | 31

scientific

Liver

Liver

clearance test

priority

Investigations

blood glucose

blood glucose

Liver glucose

Liver glycogen

glycogen

Hypoglycemia

Hypoglycemia

liver

cholesterol

total cholesterol << normal

Non esterifiedcholesterol Liver theoretical interest

GIT Dr. Shaf3y

P a g e | 32

functions

alpha feto protein

alpha feto proteins

Hepato-cellular carcinoma

cancer

alpha feto protein intra uterine

Intra uterine alpha feto protein

alpha feto protein

Intra uterine

alpha feto protein

albumin

albumin

albumin

alpha feto protein

albumin of the fetus

alpha feto protein

albumin

alpha feto protein

disease

Disease<< hepato-cellular carcinoma cirrhosis G.I.T. malignancy Spina bifida

Twins pregnancy

alpha feto protein

hepato-cellular carcinoma

alpha feto protein Hepatitis

GIT Dr. Shaf3y

P a g e | 33

cirrhosis G.I.T. malignancy

Open neural crest defect spina bifida meningeocele

female twins pregnancy

alpha feto protein

alpha feto protein

teratoma

dermoid cyst

alpha feto protein

follow up cirrhosis

cirrhosis hepato-cellular carcinoma

follow up alpha feto protein

alpha feto protein 6

For any detection

Screening

benign Malignant mass

Ultra sound

mass

mass benign malignant

alpha feto protein

Malignant

alpha feto protein

alpha feto protein

cancer

mass benign Malignant

alpha feto protein

malignant

alpha feto protein << Normal <<

GIT Dr. Shaf3y

P a g e | 34

tumor Fibrolamellar carcinoma

alpha feto protein

alpha feto protein mass

hepato-cellular carcinoma

Normal mass benign Malignant

biopsy

Marker

Des gamma carboxy prothrombin

marker

Des gamma carboxy prothrombinfibrolamellar carcinoma marker

investigations

size Liver shrunken hepatomegaly

Ascitessplenomegaly

portal vein dilated Portal hypertension

bile duct << dilated obstructive jaundice

MassLiver

CT MRI

More accurate

ERCP PTC

biliary obstruction

GIT Dr. Shaf3y

P a g e | 35

Biopsy from the liverbiopsy from the liver indication

hepatomegaly << for unknown reasons

elevated liver enzymes <<for unknown reasons

mass benign malignant

glycogen storage diseases biopsy liver

contraindications biopsy Liver

Bleeding tendency

prothrombin time <<Normal 4

Liver biopsy

platelet count

biopsy

Markedly shrunken liverMarkedly shurken liver

Organs

biopsy Massive ascites

Massive ascites

intestine gas

intestine floating

abdominal wall

contraindications biopsy

Uncooperative patientHepatic encephalopathy irritable

biopsy

sedation

hepatic encephalopathy

P

sedation Irritable pre hepatic coma

GIT Dr. Shaf3y

P a g e | 36

local anaethesia biopsy

general liver biopsy

biopsy obstructive jaundice

bleeding tendency

biopsy biliary obstruction

biliary Liver dilated

biopsy puncture

peritonitis biliary peritonitis

bleeding tendency

Liver cell failure cirrhosis

laparotomy

liver

Liver cirrhosis

Weeping liverLiver

Liver

Liver cirrhosis

Liver cirrhosis

cirrhosis

Liver

Lymphatic obstruction Liver liver cirrhotic

Is weeping on itself

Liver function

GIT Dr. Shaf3y

P a g e | 37

G.I.T.

45

152013

www.facebook.com/dr.tafreegh