Clinical biochemistry

Omar Abdelrazig Abdalla

Microbiologist, Medical educationist,
Certified trainer
How to Order the Complete
Laboratory Tests
Lab Test Menu
 Why Clinician order the Lab Test
• Clinicians take the complete Case History –
they know the symptoms.
• Based Upon History they make Provisional
Diagnosis in their mind about the case.
• Then They examine the case- Examination
by Eliciting the Clinical signs
• After Knowing the Symptoms & Signs.
 Tentative Diagnosis
• They have made the tentative Diagnosis.
• Now this diagnosis needs to be proved or
ascertained by doing the Investigations.
– Laboratory Tests.
– X ray Examination.
– CT scan Examination.
– MRI examination.
– Other special Investigations etc.
 Other possibility
• Instead of One diagnosis in their mind..
• They have more than one diagnosis..
• We call this as Differential diagnosis…

• Now the Investigations are done to

rule out one by one so that final one
diagnosis is reached for the proper
treatment of patient
 What are laboratory Tests
• These are variety of Tests done on various
fluids or tissues of the body..
• Blood- Whole Blood, Serum, Plasma,
• Urine.
• Stool
• Sputum,
• CSF etc..
 Laboratory Test Menu.
• Tests are broadly Classified in to:
• Hematology Tests.
• Biochemical tests
• Blood Bank tests.
• Serology Test
• Immunology Tests
• Parasitology tests
• Microbiology Tests
• Hormones Etc.
 Hematology Tests
• WBC count • Sickling Test
• RBC Count • Coombs Test.
• Hemoglobin • CBC-Complete Blood
• Bleeding Time Count
• Clotting Time • G6PD test
• Differential WBC • Hemoglobin Electro
• Platelet Count • Blood Cell
• Reticulocyte count Morphology
• Glycosylated HB
• ESR
• • Prothrombin Time
Blood Film for Malaria
• APTT
 Bio Chemical tests
Fasting Blood Sugar FBS • S. SGPT ( ALT)
PP Blood Sugar • S. SGOT ( AST)
Random Blood Sugar • S. Alk Phosphatase
Glycosylated HB • Total Bilirubin.
GTT Glucose curve. • Direct Bilirubin
[Link] • Indirect Bilirubin
S. Creatinine. • S Total Proteins
Creatinine Clearance Test • S Uric Acid
S. Cholesterol • S Acid Phosphatase
S. Triglycerides. • S Lithium
S. HDL • S Gamma G T
S. LDL • S Troponin I
Lipid Profile. • S LDH
 Biochemical Test
• S. SODIUM
• S. POTTASSIUM
• S. CHLORIDE
• S. CALCIUM
• S. PHOSPHORUS
• S. IRON
• S. TIBC
• S. MAGNESIUM
• S. PAMYLASE
• S. URIC ACID
• S. ACID PHOSPHATASE
• BLOOD GASSES PROFILE
• S. GAMMA GT.
• LIVER FUNCTION TEST.
• ALBUMEN I GLOB RATIO.
 Biochemical Test
• C S F EXAMINATION.
• S. LIPID PROFILE.
• S. ZINC LEVEL
• S. TRANSFERRIN
• S. PSEUDO- CHE
• S. CO2 (BI-CARBONATE).
• S. AMMONIA.
• URINARY 24 Hrs. PROTEIN
 Profiles for Anemia
• ANEMIA GROUP TESTS
• CBC
• [Link]
• S. TIBC
• S. FERRITIN
• S. TRANSFERRIN
• SICKLING TEST.
• DIRECT COOMBS TEST
 Diabetic Profile
• DIABETES TESTS
• BLOOD SUGAR FASTING
• BLOOD SUGSR P.P.
• BLOOD SUGAR RANDOM
• GTT BLOOD SUGAR CURVE
• GLYCOSYLATED HEMOGLOBIN
 Blood Bank Test

• BLOOD BANK SERVICES

• DONOR SCREENING
• BLOOD GROUP DONORS.
• FRESH BLOOD 500 CCS.
• STORED BLOOD BB.
• PACKEC RBCS 1 UNIT
• FRESH BLOOD 250 ML.
• FROZEN PLASMA
• CROSS MATCH
• PATIENTS SCREENING
 Serological Test
• W1DAL TEST
• BRUCELLA ANTIBODY TEST
• VORL I RPR QUALITATIVE.
• VORL! RPR TITRE.
• TPHA QUALITATIVE.
• TPHA TITRE.
• CRP
• RHEUMATOID FACTOR
• ASOT (ASOTITRE)
• MONO TEST
• TOXOPLASMA IgG
• TOXOPLASMA 1gM
• RUBELLA IgG
• RUBELLA 1gM
• LEISMANIA ANTIBODY.
 Serological Tests
• BILHARZIA ANTIBODY.
• CHLAMYDIA ANTIGEN TEST.
• CHLAMYDIA ANTIBODY TEST.
• HERPES SIMPLEX ANTIGEN TEST.
• HERPES I & II I9G ANTIBODY.
• HERPES SIMPLEX 1gM ANTIBODY.
• C M V 1gM ANTIBODY.
• GONOCOCCAL ANTIBODY.
• A N A ANTI NUCLEAR ANTIBODY.
• S. IgE LEVEL (SEMI QUANT)
• THYROGLOBULIN ANTIBODY.
• THYROID MICROSOMAL ANTIBODY.
• AUTO IMMUNE PANEL I
• TORCH IgG PANEL
 Serology Testing
• TORCH IgG PANEL
• TORCH 1gM PANEL
• SERUM PROTEIN ELECTROPHORESIS
• IMMUNO-ELECROPHORESIS.
• SERUM IMMGLOBULIN- M (1gM)
• SERUM IMMGLOBULIN -A (IgA)
• SERUM IMMGLOBULIN-G (IgG)
• SERUM E.B.V1RUS 1gM ANTIBODY
• T. B. ANTIBODIES
• H. PYLORI IgG Abs
 General Tests
• STOOL ROUTINE EX.
• STOOL FOR ROTA VIRUS
• STOOL FOR COMPYLOBACTER.
• STOOL FOR OCCULT BLOOD.
• URINE ROUTINE EXAMINATION
• URINE FOR ONLY SUGAR
• PREGNANCY TEST IN URINE.
• PREGNANCY TEST IN SERUM
• SEMEN ANALYSIS
• SEMEN ANALYSIS WITH FRUCTOSE.
• SEMEN PROCESSING FOR Al.
• TUBERCULINE TEST
• SKIN SCRAPPING FOR FUNGUS
 Hormones Routine Testing
• T3
• T4
• FREE T4
• TSH
• NEONATAL TSH.
• LH
• FSH
• PROLACTIN
• TESTOSTERONE
• FREE TESTOSTERONE
• PROGESTERONE
 Hormones
• ESTRAOIOL
• CORTISOL (AM)
• CORTISOL (iM)
• BETA HCG
• V 14 A.
• GROWTH HORMONE (1 SP)
• PROSTATIC SP ANTIGEN
• PARATH HORMONE.
• COMPLIMENT 3
• COMPLIMENT 4.
• ALPHA FETOPROTEIN
• C. E A
 Immunological Test
• HBSAg TEST.
• ACUTE HEPATITIS PANEL I
• ACUTE HEPATITIS PANEL II.
• PRE-VACINATION FOR HEP-B.
• HEPATITIS C ANTIBODY 3rd Gen.
• HEPATITIS A 1gM ANTIBODY.
• HEPATITIS B MARKERS.
• HIVI-HIV2 ANTIBODY ELISA.
• HEPATITIS Be ANTIGEN
• HEPATITIS Be ANTIBODY
• HEPATITIS Bs ANTIBODY
 Therapeutic Drug Monitoring
• THEOPHYLLINE
• DIGOXIN
• GENTAMYCIN
• PHENOBARBITAL
• PHENYTOIN ( DILANTIN)
• VALPROIC ACID ( DEPAKENE)
• CAR BAMAZEPINE ( TEGRETOL)
 Narcotic Drug Testing

• TRI-CYC ANTIDEPRESSANT
• CANNABINOIDS
• BENZODIAZEpINES
• OPIATES
• DA PROFILE
• SERUM ALCOHOL LEVELS
 Microbiological Cultures
• THROAT SWABCULTURE
• THROAT SWAB GRAM STAIN.
• SPUTUM FOR AFB ZN STAIN.
• SPUTUM FOR AFB CULTURE.
• SOUTUM CULTURE GENERAL.
• BLOOD CULTURE.
• URETHRAL DISCH FRESH SMEAR.
• URETHRAL DISCH CULTURE
 Microbiology Contd..
• PROSTATIC DISCH FRESH SMEAR.
• PROSTATIC DISCH CULTURE.
• CONJUCTIVAL SWAB GRAM STAIN.
• CONJUCTIVAL SWAB CULTURE.
• VAGINAL SWAB FRESH SMEAR.
• VAGINAL SWAB CULTURE.
• URINE EXAMINATION FOR AFB.
• URINE FOR CULTURE & SENSL
• GRAM STAIN FOR ANY SP.
• CULTLJRE OF ANY SPECIMEN
 Histopathology Examination
• H.P. SMALL SPECIMEN
• H.P. MEDIUM SPECIMEN
• H.P. LARGE SPECIMEN.
• PAP SMEAR CYTOLOGY.
• BUCCALSMERA SEX CHROM.
• F N A CYTOLOGY.
 Adding Value to Lab Tests Through Automation

• Lab Test
– Faster TOT
– Accuracy, Precision,
Safety
• Add information
value
– Autovalidation Lab Test
– Trending Autovalidation
Trending
• Effecting change
using lab results Life Style Adjustments
– Lifestyle changes Appropriate Therapeutics
– Selection of
therapeutics

27
 Technological Improvements for All 166 Steps in
the Diagnostic Process
Just in Time Supplies
Automated Process Control
EMR
Phlebotomy
Instruments
Trays
Reporting Designed for
Automation
Storage

RFID
2D-Codes
Recording
Analysis
Biorepository
Transportation
Pre-analytical
Mobile Robot Analytical and
Automation 28
Accessioning
 Workflow Engineering
Sampling
Tran
spor
tatio
n
Data Specimen
Receipt 0 Time
Triage
Sort
ing

Centrifuge
Conv
on

15 minutes
try ng

Pre-analytical
ssi
E n a ndl i

Repeat Processing
eyan
ce
Da er H
Ac

Conveyance
ap

ce
ta

Hematology
P

Chemistry
Manual Assay
Repeat Immunoassay

Report
Verify 60 minutes
Store
29
 Automated Work Distribution
Collection
Decision Point
Data Entry Delivery
Point
Specimen Reception Area

Centrifuge
From here
the sample is Preanalytical
• Aliquoter Analyzer Analyzer Analyzer
• Sorter under the processor
• De- one lab
• Sample Management
capper management
• Re- System (incl. Storage)
software Storage
capper
• Tube 30
Adapted from Lloyd, personal communication
 Efficient Workflow Management
• Logical workflow engineering
– Continuous flow processing
– Random Access processing
• Feedback systems
– Process monitoring
– Error detection
– Automatic system repair

31
 Workflow Management

Automation Information

Data

DATA PROCESS MANAGEMENT

• Accessioning • Sample quality
• Specimen tracking assessment
• Data logging and reporting • Optimal routing and
• Quality control documentation scheduling
• Intelligent reporting32
 Process Control Architectures
LIS Process Controller
SS/
Pre-AnalyticBM
TS Sero. Chemistry Chemistry Immu- nology

Process Controller
SS/
Pre-Analytic
TS BM
LIS Sero. Chemistry Chemistry Immu- nology

• Analytical modules connected to LIS via

process controller
• All modules communicate with one PC
• Minimizes the burden on the LIS
33
Slide: courtesy of Akira Igarashi, A&T Corporation, Japan
Labor

Pictures: [Link]
34
 Phlebotomy

Ball and Socket Closure Device

The Lasette (Cell Robotics, Albuquerque)

35
 Sample Labeling Efficiencies
• Bar coding at the point-
of-phlebotomy
B-D id
• 2D vs. 1D bar codes
– Reduce the number of
computer interfaces
– Self directing specimens
• RFID
– Current costs of RFID
around 25 cents

36
 Phlebotomy at the South Georgia Medical
Center 1998

Pre-Technology With Technology

• 671 activity steps • 535 activity steps (20%)
• 207 error prone steps • 54 error prone steps
– Multiple labels available (# (74%)
type)
• 72% reduction in
– Labeling delay
hospital-wide critical
– No phlebotomist ID
errors
– Re-labeling in lab
• 100% reduction in errors
related to specimen
management
Source: BD-id
37
 Phlebotomy Tray Preparation

BC-ROBO – mini 20 BC-ROBO – mini 40

38
Single tray system Multi-tray system
Mobile Robot Conveyance

39
 PIC & PLACE
• Automated pick up and
delivery for medical
specimens
• Does not interrupt busy
technologists
• Point of origin to point
of need connectivity

40
 Workflow Engineering

• Continuous Flow
– Sequential Processing A B C D E F
– Parallel Processing

• Random Access ABCDEFG

– Dependent analytical process
• Slows down workflow STAT
G
takes priority
• Requires good stat A
management policies B C
– Independent analytical
processes
• Most efficient and rapid A C
B
• Expensive
41
 Laboratory Automation
Conveyor Distribution Technologist Distribution

Picture of the UVA lab

here

Sonic Healthcare The University of Virginia

Sydney Australia Clinical Laboratory
Charlottesville, VA
42
 Centrifugation Options
• Robot friendly • Autofuge
• Multifuge
centrifuge
• Speedyfuge
• Axial Separation
Module

43
Video courtesy of A&T Corporation
High Speed Conveyor

Movie courtesy of Akira Igarashi - A&T Corporation, Japan

44
 A&T Modular System
• Maximizing Analyzer Throughput
– Single Tube but “High Speed” Transportation
– Buffering Module avoids Traffic Jam
– Efficient Distribution of Sample – The number of samples
loaded in Sampling Point will be monitored and controlled.

Conveyor w. Feeder Universal Connection M.

Sample Load/ Chemistry M.

Unload M. Buffering M. Immuno-a. M.
45
 Pre-analytical Workstations
Front End Processor
Pyxis
Power Processor
Beckman Coulter
Brea, CA
Pathfinder
Ai-Scientific,
Scarborough
Australia

GENESIS FE500
MODULAR, Roche Diagnostics, Indianapolis, IN Abbott/Tecan, North Chicago,46
 Maximum Efficiency Sampling
Direct Track Sampling

Aliquot
More
Analyzers

Primary
Tube

Immunoassay Chemistry

One dip, multiple analytes

A&T Corporation 47
Error Reduction Through
Automation

[Link]
48
Automated Storage and Retrieval

IDS, Japan BIOPHILE,Inc., Charlottesville, VA 49

Automated Biorepository - UVA

50
Molecular Diagnostics Automation

Gen-Probe, Tigris DTS

VerigeneTM System
with ClearReadTM

Slides courtesy of Gen-Probe and Nanosphere 51

 Gen-Probe, Tigris DTS
• Sample Throughput
– 3.5 hours to first results
– 100 samples processed per
hour following the first
result
• Sample Capacity
– 180 sample tubes
• Reagent Capacity
– 1000 tests
– Carousel designed to
accommodate menu
expansion

Slide courtesy of Gen-Probe

52
 Tigris DTS Internal Automation

Bar codes of randomly Reagent lot numbers are

loaded samples are automatically linked to
read results

Overview

Paramagnetic
Tubes are sampled
microparticle capture and
through pierceable caps 53
Pictures and video from Gen-Probe detection
 Point of Care Automation
• Broad menu devices
• Single analyte simple to use devices

Bio-Rad Micromat II Sof-Tact

CLIA waived HbA1C Abbott Laboratories
10 uL fingerstick Medisense Products
Bedford, MA
I-Stat hematology, ABG
Electrolytes, Chemistry 54
Slides courtesy of the vendors
 Self-Directed Health Care
Genomic Screen for Chronic Disease

Data Interpretation

Smart House Monitoring

Early Warning of Disease Onset

Proteomic Assessment

Personal Health Improvement

Health Intervention
55
Smart Mattress Overlay
Subject
A mattress pad
position
that measures:
• Subject position
• Body
temperature
• Breathing
• Pulse
• Room light
level
• Blood pressure2300
AD Output

2100

1900

1700
Processed vibration signal
1500
6000 6200 6400 6600 6800 7000 gives pulse rate and 56
respiration
 Monitoring System Overview
Gait
Performs data analysis,
prepares caregiver
reports, archives data,
Activity and updates software
Soft-
ware
Update
Falls
Data
Sleep and Data Server
Manager Data
Reports Data
Bed Exit Logs
Interpretation
Stove Collects data from
multiple sensor units
Care Provider
Heat wirelessly and
checks for alert
conditions
Sensors Alerts
Accesses analysis reports,
and historical data online
57
 Sleep Quality Graphs

Restful Resident

Restless Resident

58
 Personal Sensor Technologies
• Toothbrush sensors
for dental health
• Toilet sensors could
check for blood,
protein, sugar, and
medication levels
• Shower sensors for
imaging

59
Robot Delivery of Food and Other
Services to the Bedridden Patient

60
 Introduction to Clinical Laboratories
• Diagnosis begins with physical examination
by a doctor
• Diagnostic tests are important steps to
confirm a suspected diagnosis
 Clinical biochemistry

• 1) Reveal the cause of the disease

• 2) Screen easy diagnosis
• 3) Suggest effective treatment
• 4) Assist in monitoring progress of
pathological condition
• 5) Help in assessing response to treatment
 Important Note
• Disinfection:
• Chlorine (Sodium hypochlorite) is an universal
disinfectant which is active against all
microorganisms
Laboratory work flow cycle:
 The phlebotomist
• The phlebotomist :
Is the technician who collects blood, should be trained to:
• 1) Prepare specimen collection material
• 2) Instruct patient appropriately
• 3) Collect, preserve and transport specimen carefully
• 4) Separate serum or plasma properly
• 5) Maintain proper record of collection
• 6) Handle the specimen carefully
• 7) Analyze the specimen accurately
• 8) Maintain proper record of reports
• 9) Work with appropriate safety precautions
 The phlebotomy equipments

• 1) Disposable syringes or vacutainer systems

• 2) Disposable lancets
• 3) Gauze pads or adsorbent cotton
• 4) Tourniquet
• 5) Alcohol swap
• 6) Waste container
 Blood collection
The median cubital vein
is the one used for
the patient.
 Specimen rejection criteria
• 1- Specimen improperly labeled or unlabeled
• 2- Specimen improperly collected or
preserved
• 3- Specimen submitted without properly
completed request form
• 4- blood hemolysis
 Hemolysis of blood
• It is the liberation of hemoglobin from RBCs.
• Due to hemolysis, plasma or serum assumes pink to
red color.
• hemolysis causes changes in measurement of a
number of analysis such as:
• 1- Serum K
• 2- Serum [Link] P.
• 3- SGOT
• 4- SLDH
• 5- Acid phosphatase
Lab request:
 Lab request:
• 1. Full name: middle name should be included to avoid
• 2. Location: inpatient, room, unit, outpatient, address.
• 3. Patient's identification number: this identification
can be very useful for instance in the blood bank.
• 4. Patient age and sex: disease prevalence may be age-
or sex-linked.
• 5. Name(s) of the physician(s): name all of the
physicians on the case; "panic values" should be called
to the attention of the physician ordering the test; a
physician may have some specific test guidelines for
his patients.
 Lab request:
• 6. Name of the test and the source:
• 7. Possible diagnosis: essential for evaluating
laboratory results and selecting appropriate
methodology; (media selection in microbiology).
• 8. The date and time the test is to be done: some tests
must be scheduled by the laboratory; patient
preparation and diet regulations need to be
considered.
• 9. Special notation: provide relevant information to
assist the laboratory--e.g., medications taken; for
hormone assay, the point in the menstrual cycle when
the specimen was obtained
 Blood Testing
• Three different specimens
1)Whole blood
2)Serum
3)plasma
 Blood
• Red blood cells(RBCs)
• -White blood cells(WBCs)
• -Platelets
After centrifugation of blood,
the blood separate into three layers
 Blood plasma
• Plasma is the liquid component of
blood
• -It is mainly composed of
• water (92%)
• blood proteins 7%(albumin,
globulins, and fibrinogen)
• inorganic electrolytes
When a blood sample is left standing
without anticoagulant, it forms a
coagulum or blood clot
 Formation of The Clot
• Platelets to maintain the integrity of the
adherens junctions between the endothelial
cells that line the blood vessels
• Network of fibrin molecules
• Thrombin Prothrombin Ca+2 Thrombin

• Ca+2 Fibrinogen Thrombin Fibrin Clot

• Clotting factors
 Blood serum:
• Serum is the same as plasma except that
clotting factors (such as fibrin) have been
removed.
• No coagulation factors
• It is obtained by letting a blood specimen clot
prior to centrifugation.
 Procedure of Plasma Preparation:
• 1-Draw blood from patient. Select vacutainer
with an appropriate anticoagulant.
• 2- Mix well with anticoagulant.
• 3- Allow to stand for 10min.
• 4- Centrifuge the sample to speed separation and
affect a greater packing of cells.
• 5- The supernatant is the plasma which can be
now collected for testing purposes or stored (-
20C to -80C) for subsequent analysis or use.
 Procedure of Serum preparation:
• 1- Draw blood from patient. Select vacutainer
with NO anticoagulant.
• 2- Allow to stand for 20-30min for clot formation.
• 3- Centrifuge the sample to speed separation and
affect a greater packing of cells. Clot and cells will
separate from clean serum and settle to the
bottom of the vessel.
• 4- The supernatant is the serum which can be
now collected by dropper or pipette for testing
purposes or stored (-20C to -80C) for subsequent
analysis or use.
Blood collection tubes:
 Plasma Separating Tubes (PST)
Top Color Additives Principle Uses
Lavender EDTA -The strongest anti-coagulant - Hematology
-Ca+2 chelating agent - Blood bank (ABO)
- To preserve blood cells components - HbA1C
(Glycosylated Hb)

Light Blue Sodium Citrate Ca+2 chelating agent - PT: Prothrombin

Time
- PTT: Partial
Thromboplastin Time
( in case of
unexplained bleeding
and liver disease)
Green Sodium Heparin binds to Thrombin and inhibits Enzymes
Heparin or the second step in the coagulation Hormones
Lithium cascade Electrolytes (Na+, K+,
Heparin (Prothrombin Thrombin) Mg+, Cl-
Heparin
Fibrinogen Fibrin
Top Color Additives Principle Uses
Black Sodium Citrate Ca+2 chelating ESR ( Erythrocyte Sedimentation
agent Rate)
to test how much inflammation in
the patient, unexplained fever,
Arthritis, Autoimmune Disorder
Gray -Sodium Fluoride Glycolysis Glucose tests
inhibitor
-Potassium Oxalate Anti-Coagulant
Royal Blue Heparin Anti-Coagulant Toxicology
Na-EDTA Tube should not Trace Elements and metals
be
contaminated
with metals
Yellow ACD ( Acid-Citrate Anti-Coagulant DNA Studies
Dextrose) Paternity Test
HLA Tissue Typing
(Human Leukocyte Antigen)
The body used this protein to
differentiate the self-cells from non-
self cells
 Serum Separating Tubes (SST)

Top Tubes Additives Principle Uses

Red ------ Enhancing the Serology
Sometimes it has formation of blood -Antibodies
gel or silicon at the clot -Hormones
bottom of tube to -Drugs
reduce hemolysis Virology
Chemistry
Blood cross
matching before
blood transfusion
Gold ------- Serum separating Serology
It has gel at the from the blood Chemistry
bottom of the tube through the gel in
to separate serum the tube
from the blood
Diagnostic Tests
Diagnostic and laboratory Tests:
Are tools that provide information about the
client, also run to find the cause of disease or
discomfort; tests used to make a diagnosis.
Purpose of diagnostic tests:
• Help to confirm a diagnosis
• Monitor an illness
• Provide valuable information about the client’s
response to treatment
 Intratest
It focuses on specimen collection and
performing or assisting with certain diagnostic
testing.
• The nurses uses of special standard
precautions and sterile techniques
• Provide emotional and physical support while
monitoring the client as needed (e.g., V /S,
pulse oximetry, ECG).
• Correct labeling, storage, and transportation of
the specimen to avoid invalid test results.
Post test
The focus of this phase is on nursing care of the
client and follow up activities and
observations.
• Compare the previous and current test results
• Modify nursing interventions as needed
• Report the results to appropriate health team
members.
 Blood Tests
Complete Blood Count (CBC) which
includes:-
Hemoglobin
• Hgb test is a measure of the total amount of
hemoglobin in the blood
Hematocrit
• Hct measures the percentage of red blood cells
in the total blood volume
RBC count
• The number of RBC per cubic millimeter
(mm3) of whole blood
WBC or leukocyte
• The number of circulating WBC per cubic
millimeter of whole blood
Serum Electrolytes
• Ordered as a screening test for electrolyte and
acid – base imbalance.
• The most commonly ordered serum tests are
for “ sodium, potassium, chloride , and
bicarbonate”
• Evaluate renal function “ Urea, Creatinine”
• Urea, the end product of protein metabolism is
measured as BUN. Creatinine is produced in
relatively constant quantities by the muscles
and is excreted by the kidneys.
Serum Osmolality
• Serum Osmolality: is a measure of the solute
concentration of the blood. The particles
included are sodium ions, glucose, and urea.
• It is estimated by doubling the serum sodium
• Serum Osmolality values are used to evaluate
fluid balance
• Normal values are 280-300 mOsm/kg.
• An increase in Osmolality indicates a fluid
volume deficit
Drug monitoring
Is conducted when the client is taking a
medication with narrow therapeutic range such
as digoxin.
• This includes monitoring drawing blood
samples for peak and trough levels to
determine if the blood serum levels of a
specific drug are at a therapeutic level and not
a sub therapeutic or toxic level.
• Peak level: the highest concentration of the
drug in the blood serum
• Trough level: lowest concentration
Arterial Blood Gases “ABGs”

• Take specimen of the ABG from the radial, Brachial,

femoral arteries.
• Need to apply pressure to the puncture side for about
5-10 minutes after removing the needle.
Blood Chemistry
• Certain enzymes such as Lactic dehydrogenase
“LDH”, Creatine Kinase “CK” , serum
glucose, hormones such as thyroid hormone,
cholesterol and triglycerides.
• A common test is the glycosylate hemoglobin
“HbA1C”, which is a measurement of blood
glucose that is bound to hemoglobin. HbA1C
is reflection of how well blood glucose levels
have been controlled during the prior 3 to 4
months.
Capillary Blood Glucose

• Measure blood glucose when frequent tests are

required or a veinpuncture cannot be performed.
• Less painful, easily performed
Stool Specimens
• Reasons for testing feces include the
following:
• To determine the presence of occult blood
“hidden blood”. This test is referred to as the
guaiac test.
• To analyze for dietary products and digestive
secretions. An excessive amount of fat in the
stool (steatorrhea) can indicate faulty
absorption of fat from the small intestine.
Decreased amount of bile in stool indicate
obstruction in bile flow from liver and
gallbladder to the intestine.
• To detect the presence of ova and parasites.
When collecting specimen for parasites, it is
important to send the specimen as soon as
possible while it is still warm.
• To detect the presence of bacteria or viruses,
so the container must be sterile and aseptic
technique in collection.
Collecting Stool Specimens
Before obtaining the specimen, the nurse must determine
the reason for the collecting the stool specimen and the
correct method of obtaining and handling.
Nurse need to give the clients the following instructions:
• Defecate in a clean bedpan or bedside commode.
• Do not contaminate the specimen by urine or menstrual
discharge.
• Do not place toilet tissues in the bedpan after defecation.
• Notify the nurse as soon as possible after defecation to
send the specimen as soon as possible.
When obtaining the specimen the nurse
should:-
• Follow medical aseptic technique
meticulously.
• Wear disposable gloves to prevent hand
contamination and take care not to
contaminate the outside of the specimen
container.
• Use one or two clean tongue blades to transfer
the specimen to the container.
• The amount of stool to be sent depends on the
purpose for which the specimen is collected.
• Label the specimen and the laboratory
requisition have the correct information on
them.
• Sends the specimen to the laboratory
immediately.
• Document all relevant information, date, time
of collection and all nursing assessments”
color, odor, consistency and amount of feces”.
Testing Feces for Occult Blood

• Use of chemical reagent substance to detect the

presence of the enzyme peroxidase in the hemoglobin
molecule.
• A blue color indicates a guaiac positive result, that is,
the presence of occult blood. No color change or any
color other than blue is a negative finding, indicating
the absence of blood in the stool.
• Certain foods, medications, and vitamin C can
produce incorrect test results.
• False positive results can occur if the client has
recently ingested (a) red meat (b) raw
vegetables or fruits, (c) certain medications
that irritate the gastric mucosa and cause
bleeding such as aspirin, NSAID,
anticoagulants.
• False – negative results can occur if the client
has taken more than 250mgper day of vitamin
C up to 3 days before the test – even if
bleeding is present.
 Positive guaiac test shown on right, as
would be seen for this patient. Negative
result (on left) included for comparison.
Urine Specimens
The nurse is responsible for collecting urine specimens
for a number of tests: Clean voided specimens for
routine urinalysis, clean – catch or midstream urine
specimens for urine culture, timed urine specimen,
indwelling catheter specimen.
Clean voided Urine Specimen
• Usually done on the first voided specimen in the
morning
• At least 10 ml of urine sufficient for routine analysis
• Client who is disabled, seriously ill or disoriented may
need to use a bedpan or urinal in bed, these need
special instructions:
• The specimen must be free of fecal
contamination
• Don’t discard the toilet tissue in bedpan
• Put the lid tightly on the container to prevent
spillage of the urine.
• If the outside of container is contaminated, clean
it with a disinfectant.
Clean-Catch or Midstream Urine Specimen
It is collected when a urine culture is ordered to
identify microorganisms causing urinary tract
infection. Care is taken to ensure that the specimen is
as free as possible from contamination around the
urinary meatus.
• Clean – catch specimens are collected into a sterile
specimen container with a lid.
• Clean the urinary meatus with antiseptic solution
• Instruct the client to start voiding
• Collect 30-60 ml of urine in the container.
• Label the specimen and transport it to the laboratory.
Timed Urine Specimen
It requires collection of all urine produced and
voided over a specific period of time, ranging
from 1-2 hours to -24 hours. Each voiding of
urine is collected in a small, clean container
and then emptied immediately into the large
refrigerated bottle or carton.
 It is done for the following purposes:
• To assess the ability of the kidney to concentrate and
dilute urine.
• To determine disorders of glucose metabolism such
as DM.
• To determine levels of specific constitutes such as
albumin, creatinine.
To collect the time urine specimen:
– Obtain the specimen with preservative from the
laboratory. Label the container with identifying
information for the client, the test to be performed,
time started, and time of completion.
– Provide a clean receptacle to collect urine (bedpan).
– Post signs in the client’s chart, room, alerting the
person to save all urine during the specified time.
– At the start of the collection period, discard the first
voiding
– Save all urine produced during the time collection
period in the container.
– At the end of collection, ask the pt to void the last time
and add them in the container.
– Record collection of the specimen, timed started and
completed.
Urine Testing

Several simple urine tests are often done by nurses on

the nursing units. These include tests for specific
gravity, PH, and the presence of abnormal constituent
such as glucose, ketones, protein.
• Specific gravity – is indicator of urine concentration,
or the amount of solutes present in the urine
• Normally ranges from 1.010 to 1.025
• PH is measured to determine the relative acidity or
alkalinity of urine (7 is neutral, less than 7 is acidic,
greater than 7 is alkaline).
• Glucose – urine is tested for glucose to screen
clients for diabetes mellitus and to assess
clients for abnormal glucose to tolerance
during pregnancy.
• Ketones – ketones bodies a product of the
breakdown of fatty acids normally are not
present in the urine.
• Protein
• Occult blood
• Osmolality – is measure of the solute
concentration of urine. Normal values are 500
to 800 mOsm/kg.
Sputum specimen
Sputum is the mucous secretion from the lungs,
bronchi, and trachea.
A sputum trap is used when the specimen is
obtained by suctioning.
Sputum collection for the following purposes:
• For culture and sensitivity to identify a specific
microorganisms
• For cytology to identify the origin, structure, function
and pathology of cells.
• For acid-fast bacillus for TB.
• To assess the effectiveness of therapy.
Throat Culture
A throat culture sample is collected from the mucosa
of the oropharynx and tonsillar regions using a
culture swab.
Obtaining a throat culture is an invasive procedure
that requires the application of scientific knowledge
and potential problem solving to ensure client safety.
 Visualization Procedures
It includes indirect visualization (noninvasive) and
direct visualization (invasive) techniques for
visualizing body organ and system function.

Clients with Gastro intestinal Alteration:

Direct visualization techniques include:
• Anoscopy: viewing of the anal canal
• Proctoscopy: viewing of the rectum
• Proctosigmoidoscopy: viewing the rectum and
sigmoid colon
• Colonoscopy: viewing of the large intestine.
Indirect visualization of the gastrointestinal tract is
achieved by:
X-rays of gastrointestinal tract can detect structure,
obstructions, tumors, ulcers, inflammatory diseases or
other structural changes such as hiatal hernias.
Visualization of the tract is enhanced by the use of a
barium. For examination of the upper gastrointestinal
tract or small bowel, the client drinks the barium
sulfate (barium swallow). For examination of the
lower gastrointestinal tract, the client is given an
enema containing the barium (Barium enema).
Barium Swallow
Upper endoscopy
Clients with Urinary Alterations
Visualization procedures also may be used to evaluate
urinary function.
• An X – ray of the KUB: Kidneys, Ureters, Bladder
• IVP (Intravenous pyelography) – contrast medium
is injected intravenously.
• Retrograde pyelography – contrast medium is
instilled directly into the kidney pelvis via the
urethra, bladder, and ureters following injection or
instillation of the contrast medium, x- ray are taken to
evaluate urinary tract structures.
• Ultrasonography: noninvasive test that uses
reflected sound waves to visualize the kidney.
• Cystoscopy: a lighted instrument inserted through the
urethra to visualize the bladder, urethral orifices
and urethra.
Clients with cardio pulmonary Alterations

• ECG: Electrocardiography, recording of the heart’s

electrical activity.
• Electrocardiogram: Detect arrhythmias and
alteration in conduction indicative of myocardial
damage, enlargement of the heart, or drug effects.
• Stress electrocardiography: Assess the client’s
response to an increased cardiac workload during
exercise.
• Angiography: invasive procedure requiring informed
consent of the client. A radiopaque dye is injected
into the vessels to be examined. Using x-rays the flow
through the vessels is assessed and areas of narrowing
or blockage can be observed.
• Echocardiogram: noninvasive test that uses ultra
sound to visualize structures of the heart and evaluate
left ventricular function.
Lung scan
• Also known as V/Q (Ventilation / perfusion) scan,
records emissions from radioisotopes that indicate
how well gas and blood are traveling through the
lungs.
• Laryngoscopy and bronchoscopy are sterile
procedure. Tissue samples may also be taken for
biopsy.
Computed Tomography (CT) or (CAT)
Painless, noninvasive x-ray procedure that has the
unique capabilities of distinguishing minor
differences in the density of tissues. It produce a
three – dimensional image of the organ or structure.
Magnetic Resonance Imaging (MRI)
Is a noninvasive diagnostic scanning technique in which
the client is placed in a magnatic field. MRI provides a
better contrast between normal and abnormal tissue than
the CT scan. For visualization of the brain, spine, limbs,
and joints, heart, blood vessels, abdomen and pelvis. The
procedure lasts between 60 and 90 minutes.
Aspiration/Biopsy

Aspiration: withdrawal of fluid that has abnormally

collected such as pleural cavity, abdominal cavity.
Biopsy: removal and examination of tissues. Usually
performed to determine a diagnosis or to detect

malignancy. Both aspiration and biopsy it needs

sterile techniques.

“Determine if the facility requires a signed informed-

consent from the aspiration / biopsy procedures”
Lumbar Puncture
In lumbar puncture “LP” CSF is withdrawn
through a needle inserted into the
subarachnoid space of the spinal canal
between the third and fourth lumbar vertebrae
or between the fourth and fifth lumbar
vertebrae.
Abdominal Paracentesis
Normally the body creates just enough peritoneal
fluid for lubrication. The fluid is continuously
formed and absorbed into the lymphatic
system.
Ascites: large amount of fluid accumulates in the
abdominal cavity.
Abdominal Paracentesis: carried out to obtain a
fluid specimen for laboratory study and to
relieve pressure on the abdominal organs due
to the presence of excess fluid. A common site
for abdominal Paracentesis is the midway
between the umbilicus and the symphysis
pubis on the midline. Normally about 1,500 ml
is the maximum amount of fluid drained at one
time to avoid Hypovolemic shock.
 Thoracentesis
Normally, only sufficient fluid to lubricate
the pleura is present in the pleural cavity.
However, excessive fluid can be
accumulating as a result of injury,
infection, or other pathology. It is
performed to remove the excess fluid or air
to ease breathing. Also it is performed to
introduce chemotherapeutic drugs
intrapleurally.
This is usually a sitting position with the arms
above the head, which spreads the ribs and
enlarges the intercostals space. Or in which the
client leans forward over a pillow.
A site on the lower posterior chest is often used
to remove fluid, and a site on the upper
anterior chest is used to remove air.
Bone Marrow biopsy
Biopsies are performed on many different types of
tissues such as bone marrow, liver, breast, lymph
nodes and lungs. The bones of the body commonly
used for a bone marrow biopsy are the sternum, iliac
crests, anterior or posterior iliac crest spines, and
proximal tibia in children. The posterior superior iliac
crest is the preferred site with the client placed prone
or on the side. 1-2 ml of bone marrow was withdraw.
Liver biopsy
It is performed at the client’s bedside, in which a
sample of liver tissue is aspirated. A physician
inserted a needle in the intercostals space between
two of the right lower ribs and into the liver or
through the abdomen below the right the right rib
cage. The nurse applies pressure to the site to
prevent bleeding, often by positioning the client
on the biopsy site.
Laboratory Testing – Basic
Clinical Chemistry
 Testing - Basic Clinical Chemistry
Purpose of Clinical Chemistry Tests
– Measure levels of substances found normally in
human blood that have biological functions.
Examples: Glucose, Calcium
– Detect or measure non-functional metabolites or
waste products. Examples: Creatinine, Blood
Urea Nitrogen (BUN)
 Testing - Basic Clinical Chemistry
– Detect or measure substances that indicate cell
damage or disease. Examples: Liver enzymes,
such as ALT, Cardiac enzymes, such as CK-MB
– Detect or measure drugs or toxic substances.
Examples: Dilantin, Drugs of abuse screen
 Testing - Basic Clinical Chemistry
• Types of Specimens for Chemical Analysis
– Whole blood, serum or plasma. The most
common specimen is serum, collected in a tube
with no anticoagulant so that the blood will clot.
– Urine – often 24 hour collections
– Others – Cerebrospinal Spinal Fluid (CSF) and
other fluids
 Testing - Basic Clinical Chemistry

• Collection and Handling of Blood Specimens for

Chemical Analysis
– Blood collection tubes for obtaining serum -
Serum Separator Tubes (SST) do not have an
anticoagulant but do contain a gel substance
which will form an interface between the clot and
the serum when the blood specimen is
centrifuged. These tubes are sometimes referred
to as “Tiger Tops”.
Testing - Basic Clinical Chemistry
 Testing - Basic Clinical Chemistry
Blood collection tubes
for obtaining plasma
 Testing - Basic Clinical Chemistry
Patient preparation; time of collection; & effects of
eating on chemistry analysis

Some specimens are increased or decreased

after eating (ex. Glucose, triglycerides), so it is
important to know what the test and collection
method call for. Specimens for these tests are
usually collected in a fasting state.
Testing - Basic Clinical Chemistry
• Sometimes serum or
plasma appears
lipemia (milky) after
a patient has eaten a
fatty meal. Lipemia
affects most
chemistry analyses.
The blood must be
recollected when the
patient is fasting.
Testing - Basic Clinical Chemistry
• Clinical Chemistry Tests
• Normal or Reference Values – range of values
for a particular chemistry test from healthy
individuals
• Chemistry Panel grouping – some tests are
“bundled” according to the system or organ
targeted. Examples: thyroid panel, liver panel,
cardiac panel, kidney panel, basic metabolic
panel, etc.
Testing - Basic Clinical Chemistry

• Commonly Performed Chemistry Tests or

Analytes
• Proteins – essential components of cells
and body fluids. Some made by body,
others acquired from diet. Provides
information about state of hydration,
nutrition and liver function, since most
serum proteins are made in the liver.
Testing - Basic Clinical Chemistry
• Electrolytes – sometimes called “lytes”
• Includes sodium (Na), potassium (K),
chloride (Cl) and bicarbonate (HCO3-)
• Collectively these have a great effect on
hydration, acid-base balance and osmotic
pressure as well as pH and heart and
muscle contraction
• Levels differ depending on if inside vs.
outside cells
• Important in transport of substances into
and out of cells
 Testing - Basic Clinical Chemistry
– Minerals
• Calcium
– Used in coagulation and muscle contraction
– 99% is in skeleton and is not metabolically active
– Influenced by vitamin D, parathyroid hormone,
estrogen and calcitonin
– Hypercalcemia – occurs in parathyroidism, bone
malignancies, hormone disorders, excessive vitamin
D, and acidosis; may cause kidney stones
– Hypocalcemia – can cause tetany; occurs in
hypoparathyroidism, vitamin D deficiency, poor
dietary absorption and kidney disease
Testing - Basic Clinical Chemistry
• Phosphorus
– 80% in bone and rest in energy compounds such as
ATP
– Influenced by calcium and certain hormones
• Iron
– Essential for hemoglobin
– Deficiency results in anemia; may be caused by lack
of iron in diet, poor absorption, poor release of
stored iron or loss due to bleeding
– Increased in hemolytic anemia, increased iron
intake or blocked synthesis of iron-containing
compounds, such as in lead poisoning
 Testing - Basic Clinical Chemistry
– Kidney Function Tests
• Serum Creatinine
– Best test for overall kidney function; not affected by
diet or hormone levels
– Waste product of muscle metabolism
– Serum creatinine rises when kidney function is
impaired
Testing - Basic Clinical Chemistry
• BUN (Blood Urea Nitrogen)
– BUN is surplus amino acids that are converted to
urea and excreted by kidneys as a waste product
– BUN influenced by diet and hormones, so it is NOT
as good an indicator of renal function as serum
creatinine levels
– BUN increased in kidney disease, high protein diet,
and after administration of steroids
– BUN decreased in starvation, pregnancy and in
persons on a low protein diet
Testing - Basic Clinical Chemistry
Uric Acid
Formed from breakdown of nucleic acids and excreted
as a waste product by kidneys
Increased in kidney disease, but most often used to
diagnosis gout (pain in joints, mainly big toe, due to
precipitated uric acid crystals)
Also increased in increased cell destruction, such as
after massive radiation or chemotherapy
Testing - Basic Clinical Chemistry
Liver Function Tests
Liver functions:
Synthesizes glycogen from glucose
Makes plasma proteins (albumin, lipoproteins, coagulation
proteins)
Forms cholesterol and degrades it into bile acids, which
emulsifies fats for absorption
Stores iron, glycogen, vitamins and other substances
Destroys old blood cells and recycles components of
hemoglobin
Testing - Basic Clinical Chemistry
Testing - Basic Clinical Chemistry
Total Bilirubin
Waste production of hemoglobin breakdown
Increased in excessive RBC breakdown, such as
hemolytic anemia, or impaired liver function or some
sort of obstruction, such as a tumor or gall stone
Testing - Basic Clinical Chemistry
• Liver Enzymes – levels increase following damage to
liver tissues
– Alkaline Phosphatase (ALP or AP) - Greatly increased in liver
tumors and lesions; moderately increased in diseases such as
hepatitis
– Alanine Aminotransferase (ALT; formerly called SGPT) -
Increases up to 10x in cirrhosis, infections or tumors and up to
100x in viral or toxic hepatitis
Testing - Basic Clinical Chemistry
– Gamma Glutamyl Transferase (GGT) -
Often used to monitor patients recovering
from hepatitis and cirrhosis
– Lactate Dehydrogenase (LD) - Increased in
liver disease and following heart attacks

– Asparate Aminotransferase (AST; formerly

called SGOT) - Increased in liver disease,
but also in heart attacks
Testing - Basic Clinical Chemistry
Cardiac Function Tests
Creatine Kinase (CK) - Widely used to
diagnosis and monitor heart attacks
Troponins
Only present in heart muscle,
making it a more accurate
indicator of heart attack than CK
Cardiac Troponin T (cTnT)
Cardiac Troponin I (cTnI)
Testing - Basic Clinical Chemistry
Lipid Metabolism Tests
Cholesterol
Present in all tissues
Serves as the skeleton for many
hormones
Recommended to be less than 200
mg/dL in adults)
LDL = “bad” cholesterol; HDL = “good”
cholesterol
Testing - Basic Clinical Chemistry
– Triglycerides
» Main storage form of lipids, comprising
95% of fat tissue
» Hyperlipidemia – having high blood levels
of triglycerides – may increase risk of
heart attack
• Carbohydrate Metabolism Tests
– Glucose - Largely regulated by insulin
Testing - Basic Clinical Chemistry
Testing - Basic Clinical Chemistry
• Thyroid Function Tests
– Thyroid Stimulating Hormone (TSH) - Inverse
relationship to thyroid function (the higher
the TSH, the lower the thyroid function and
vice versa)
– Other less common thyroid tests include T3
and T4
– Hypothyroidism – underactive thyroid gland
– Hyperthyroidism – overactive thyroid gland
 Testing - Basic Clinical Chemistry
Photos of some clinical chemistry laboratories
 Laboratory tests are ordered
by the clinician for one of four reasons:

• Screening: - used in the general population –

- to find silent disease

• Case finding: - to find disease

in specific clinical populations at risk

• Diagnostic testing: - as rule-in / rule-out tool to :

- convince patients of their benign condition, -
- to justify the clinicians procedere, -
- for medico-legal safeguarding

• Monitoring: used to:

- monitor the progress of disease,
- “ response to therapy,
- “ concentration of medication.
 Sample Collecting:

body substances: blood, urine, faeces, sweat etc.

collected in : URINE/STOOL/BLOOD - CONTAINERS

Phlebotomist’s Equipment :
• VACUTAINER TUBES -
o EDTA (Lavender) VACUTAINER NEEDLES
o SST (Gold/
Serum) o 21 Gauge (Green)
o SST (Speckled/Serum) o 21 Butterfly (Green)
o Citrate/Clotting (Lt Blue) o 22 Gauge (Black)
o Fluoride Oxalate/Glucose o 23 Gauge Butterfly
(Grey) (Blue)
o Lithium Heparin (Green) o VACUTAINER BARREL
o No Additive (Red)
o Sod. Heparin (Dark Blue)
 How can one define a ‘Healthy Population’ ?
• Health or Disease diagnosis
~ relies on findings of :
true-negatives or true-positives
~ hampered by
false-negatives or false positives

• Is it possible to find a truly ‘normal individual’ ? – or a healthy population

whose physiology is truly perfect ?

• Without an ‘ideal population’ – any stated reference range will be falsly

broad –( the 95% water-shed);

• Optimal metabolic ranges may be quite narrow for many biochemical

parameters
 Laboratory / Path-Lab. Tests
• Routine Health Service Special Health Service
tests : tests:

• Cytology
• Blood Chemistry
• Microscopy
• Blood Film Examination
• Aspirated Material :
• Urine-analysis - Exsudates
- Transudates
• Microbiology
 Blood Chemistry
• Electrolytes
• Lipid-Profile
• Diabetes Check, RBS, GTT, HBA1c
• Renal Profile
• Hormone Assays Progesteron Estradiol, Testosterone, DHEA, ACTH,
Catecholamines
• Serum Protein Electrophoresis
• Inflammation Markers ESR, CRP
• Tumor Markers
PSA, AFP, CEA, β-HCG
CA153. CA27-29, CA19-9, CA 125, HER-2-neu,

• Miscellanious LDH, AP
 Serum Sodium (Na+)
- major extra-cellular cation
• regulates blood and volume by its osmotic
activity in the plasma (Osmolality) and in the
lymphatic tissues
• excreted by the kidneys, sweating

• increased: Cushing’s Syndrome, drug-effects

• decreased: Addison’s Disease, renal failure,

metabolic acidosis, malignancies, drugs
 Serum Potassium (K+)
- major intra-cellular cation
- distal tubular secretion dependent on: mineralcorticoids,
» acid-base balance
drugs

• major influence on muscle activity

• if unbalanced :
– diagnosis whether Hypo- or Hyper-kalaemia required
– diagnosis whether Hypo- or Hyper-Adrenalism present
– risk of metabolic / respiratory alkalosis or acidosis present
 Plasma Creatinine
by-product from Creatine-metabolism

• – single most useful measurement of renal function

• normally varies little throughout the day
• best monitoring tool for : renal secretory function
glomerular filtration rate GFR
 Urea NH2CONH2

• - produced by protein consumption and the

formation of ammonia

• – raised levels (Uraemia/ Azotaemia)

- sign of chronic renal failure,
- can have pre-renal, renal and post-renal cause
- can lead to Uraemic Syndrome, nausea, confusion . .
 Uric Acid

• - end product of purine metabolism

• ~ ↑ (Hper-uricemia) - predictive of gout ,

• ~ ↑ poly-cystic kidney disease, anemias
• ~ ↑ hypothyroidism
• ~ ↑ diuretics, salicylate
 Calcium (Ca2+)

• defines clinical diagnosis whether Hypo- or Hyper-calcaemia

• clinically linked with 1-ary Hyper-Parathyroidism,

• “ “ effects of drugs, radiation, malignancy,

• clinically linked with Hypo-Parathyroidism :

associated with : other endocrine disorders, -
symptomatically : cramps, spasms, tetany. nail + skin disorders
 Diabetic Monitoring

• Normal Serum Glucose Concentration 75mg-110mg/dl

4.2 - 6.4 (mmol/l in SI – units

• Glucose Tolerance Test (GTT) < 7.8 (8.9 mmol/l )

(2 hr post-glucose loading analysis)

• Glycosylated Hemoglobin ( HbA1c) n.r. ( 3.8 – 6.4)

dependent on circulating erythrocyte (120 days)

 Further Glycaemic Testing becomes

indicated after symptom development: - excessive thirst, glycosuria, skin irritation
(if Random BS > 11 mmol/l  Diabetes )

- fasting glucose > 7 mmol/l

- plasma glucose 2 hrs after GTT-loading > 11.1

- HBA!c, plasma-lipid profile, . . .

 Serum-Lipids
• Cholesterol – insoluble in water – carrier proteins : ‘Lipoproteins’

desirable borderline high .

Total Cholesterol < 200 200 – 240 > 240 [mg/dl ]
5.2 6.1 [ S.I.]
Triglycerides < 150 150 – 200 > 200
1.7 2.25
LDL- Cholesterol < 130 130 – 160 > 160
2.6 4.1
LDL- Cholesterol > 60 if less than 39
1.5 1.
 Liver Function Tests

• Serum Transaminases
• Serum Aspartate Transaminase (AST or SGOT)
• Serum Alamine Aminotransferase (ALT or SGPT)
• Serum Alkaline Phosphatase (AP)
• Serum Gamma Glutamyl Transpeptidase (GGT)
• Serum Bilirubin
• Serum Albumin
 Bilirubin
~ waste-product of the erythrocyte degradation cycle

→ Serum ( free or un-conjugated B. - as ‘bilirubin-albumin complex’ )

( conjugated in liver - as ‘bilirubin glucoronide’ )

• ↑ conjugated - hepatobiliary disease

- obstructive post-hepatic jaundice

• ↑ un-conjugated - Gilbert’s Syndrome, neonatal jaundice

- haemolysis, pre-hepatic jaundice

→ Urine (uro-bilinogen) hemolytic anemia, toxic hepatitis,

mononucleosis
 Clinical Hematology examines ( sample bottle EDTA)
• BLOOD CELL DEVELOPMENT of :
Red Blood Cells (RBCs, Erythrocytes) White Blood Cells (WCs, Leukocytes)
• BLOOD CELL COUNTS
Units Reported By Automated Counting: (RBCs), (WC), Platelets
Complete blood count CBC : HEMOGLOBIN - Variants
HEMATOCRIT (PACKED CELL VOLUME)
REDCELL- Count - with morphology
- MCV, MCH, MCHC,
PLATELETS
WHITE-CELL- Count with morphology
WHITE-CELL- Count with DIFFERENTIAL Count
Neutrophils
Eosinophils
Basophils
onocytes
Lymphocytes
EXAMINATION OF THE PERIPHERAL BLOOD FILM

• Microscopic Examination of the Blood Film Normal Leukocyte Morphology

• Blood Cell Alterations

• ADDITIONAL HEMATOLOGY PROCEDURES

• Reticulocyte Counts
• Erythrocyte Sedimentation Rate (ESR)
• Blood-Coagulation
 Red-Cell (Erythrocyte) –Population
PERIPHERAL BLOOD FILM : differentiation by Color, Shape:

Macro-cytosis →
Megaloblastic Anemia

-normochromic Micro-cytosis
deficincy-An.
→ Iron-

- hypochromic Aniso-cytosis
Poikolo-cytosis
- hyperchromic Presence of : Sickle-cells
Target-
cells

Helmet-cells
Spherocytes

Hemoglobin Variants S, C, D, E Hemoglobin-Derivatives →

Microcirculation
(Met-, Oxy-, Carboxy-, Cyanomet- H. )
 White-Cell (Leukocyte) -Population
PERIPHERAL BLOOD FILM :
if increased:
Myeloid Series (⅔) → (leucocytosis)
Neutrophils → (neutrophilia )
Eosinophils → (eosinophilia )
Basophils
Monocytes
 Lymphocytes (⅓) – small, large, reactive → (lymphocytosis)

DEFICIENCIES:
Leukopenia, Neutropenia, Lymphocytopenia etc …
 Fatigue
Signs I Symptoms I Findings
• Ongoing fatigue
- reduced daily activity
- very limited exercise tolerance
• Muscle pain
- worse after exercise
• Migrating polyarthralgia

• Recurrent headaches

• Depression

• Cognitive disturbances

• Low blood pressure / Postural hypotension

• Commonly reported Symptoms & Findings
from a large number of ‘dys-functional individuals’ :

• Fatigued – easily out of puff

• Muscle weakness, muscle pain, - worse after exercise
• Migrating polyarthralgia, joints ache, - feel stiff
• Sleep disturbance -Insomnia - Hypersomnia
• Low grade feverishness, sweating disorder,
• Chronic sore throat, - swollen lymph nodes
• Recurrent headaches, unexplained depression
• Cognitive disturbances, - snowflakes, buzzing noises,
- crawling sensation, brain fag
• Low morning blood pressure, - postural hypotension
• Reduced daily activity, - very limited exercise tolerance
 Disease Labeling or Health Monitoring ?

Traditional Lab-testing Functional Lab-Assessment

What ? Why?

identify single cause Complex InterRelationships

Separation of Symptoms Connectedness of Symptoms

quantifies Pathology quantifies Function

 . . is there a shift in the spectrum of diseases
that we see and experience ?

. . need for new biochemical

( or other ! ) markers ? :
- not only to diagnose disease
- sensitive to monitor metabolism more
dynamically
- treatment progress “ “

• T1 – T2 responses
• Neurotransmitters, Cytokines, Trace-elements
• Antioxidfant-Activity, DNA-adducts
• Endocrine Disruptors , Free
• pleo-morphic shift of pathogens, life-blood-analysis
• Apoptosis
 Microbial Pathogens
• VIRUSES -100 nanometers,
multiply through host DNA

• BACTERIA - at least 10 times larger than viruses,

1 mcmr (1 millionth of a meter) - reproduce independently

SINGLE-CELL - at least 100 times larger, 0.1 millimeter long

PARASITES

• MULTI CELLULAR - can be seen with the naked eye

PARASITES
=======================================================
Pleomorphism = theory of dynamic changes and
transmutations between pathogens
Acid Base Disturbance
 R.R (Arterial)

Bicarbonate: 21-28 mmol/L

PCO2: 34-46 mmHg

 Respiratory disturbance

- changes in PCO2
- compensatory changes in bicarbonate conc

(In the same direction)

Limitig the pH changes
 respiratory acidosis
e.g.: respiratory failure
PCO2 rises------------- respiratory acidosis
Bicarbonates also rise to compansate

HCO3
PCO2
e.g.: Ph=7.25, HCO3= 27 mEq/L, PCO2=60 mmHg
 Respiratory alkalosis
Overventilation: washout of PCO2, it will fall
Respiratory alkalosis with compansatory fall
in bicarbonate
HCO3
PCO2
e.g.: pH=7.48, HCO3=21mEq/L,
PCO2=28mmHg
 Causes of respiratory acidosis:
Causes of respiratory acidosis:
1-lung disease: e.g: bronchitis, emphyseama, …
2- Air way obstruction
3- Disorder of thoracic cage: trauma
4- Respiratory center disturbnce: drugs,accidents
5- Neuromaskular disorder: polio
 Causes of respiratory alkalosis:
Overventilation:
- central: stimulation by hypoxia

- Prepheral; improperly controlled

mechanical ventilation
 Metabolic disturbance
- changes in the level of bicarbonate

- with compansatory respiratory responce

(In the same direction)

Limitig the pH changes
 Metabolic acidosis
- bicarbonate level decrease……..lower pH

- compansatory reduction in PCO2

HCO3
PCO2
e.g.: pH=7.28, HCO3= 12mEq/L,
PCO2=27 mmHg
 Metabolic alkalosis
- bicarbonate level increase…..increase pH

- compansatory increase in PCO2

HCO3
PCO2
e.g.: pH=7.47, HCO3= 42mEq/L,
PCO2=55 mmHg
 Causes of Metabolic acidosis
1-retention of H+: (endogenous)

- Renal Failuer, retention of sulfate and

phosphate
- DKA
- Lactic acidosis
 Causes of Metabolic acidosis(cont,)
2-retention of H+: (exogenous)

- Asprin overdose (salycylate retention)

- Methanol poisoning
 Causes of Metabolic acidosis(cont,)
3- bicarbonate loss:
-from kidney:
RTA: failure of bicarbonate regeneration and
absorption

- therapy with carbonic anhydrase inhibitors

(acetzolamide)…block bicarbonate regeneration
 Causes of Metabolic alkalosis
1- ingestion of alkali (Na HCO3)

2- loss of H+ due to:

severe vomiting, e.g: pyloric stenosis,
or diuretic therapy,
or Cushing syndrome.
 Acid Base Disturbance
Acidosis Respiratory Metabolic
HCO3 HCO3
pH PCO2 PCO2

Alkalosis HCO3 HCO3

PCO2 PCO2
pH
 N.B:

Severe vomiting….loss of Cl, H+, K+ and volume of

ECF….. aldosterone released ….exagerate loss
of K+,….hypokalemic metabolic alkalosis
Diabetes Mellitus
 What is diabetes?
a clinical syndrome in which the central feature is a
chronic elevation of the blood glucose concentration
- this results in a range of pathologies.
Due to a deficiency of insulin (absolute) or a resistance
to insulin (relative).
The chronic hyperglycaemia is associated with long
term tissue damage, especially the blood vessels,
nerves, heart, kidneys and eyes.
 Insulin
- consists of two amino acid chains linked by two disulfide bridges

- proinsulin in pancreatic beta cell is cleaved to insulin and a connecting

peptide (c-peptide levels can be used to measure amount of endogenous
insulin production, as commercial insulin preparations do not have c-
peptide)

- main stimulus for release is glucose, but release can also be triggered by
amino acids, fatty acids and ketone bodies.

- effects of insulin are anabolic , promotes cell growth, promotes peripheral

uptake of glucose – especially in skeletal muscle cells, encourages storage
(as muscle glycogen)
 Deficiency of insulin:
- catabolic effects contribute to signs and symptoms of
diabetes

- glycogen is broken down to glucose; proteins to

amino acids; fats to glycerin and free fatty acid

- hyperglycaemia is promoted by increasing

glycogenolysis and glycogenesis and a reduction in
glucose utilisation
 Classification of diabetes mellitus
Previous classification:

1. Juvenile onset diabetes/insulin dependent

diabetes mellitus

2. Adult onset diabetes/non-insulin dependent

diabetes mellitus
 New classification:
1. Type 1: Immune mediated (could be in
children with a more rapid onset (classic) or
adults with a slower onset
2. Type 2: Insulin resistant
3. Other specific types (eg certain genetic
defects; drug induced; etc)
4. Gestational diabetes mellitus
 Diagnosis of diabetes mellitus:
Classical symptoms of:

- hyperglycaemia
- polyuria (excessive urination); -
polydipsia (thirst);
- nocturia (nocturnal urination); - lethargy;
weight loss
- complications
Criteria for diagnosis: (hyperglycaemia )

1. Classical symptoms plus a random plasma glucose

concentration > 200 mg/dl
or
2. Fasting plasma glucose > 126 mg/dl (fasting is no
food for > 8 hours)
or
3. 2 hour plasma glucose greater than 200 mg/dl
during oral glucose tolerance test (OGTT)
 Criteria for exclusion:

1. Fasting plasma glucose <100 mg/dl

or
2. a random plasma glucose concentration
<140 mg/dl

is sufficient to rule out diagnosis of DM

 Impaired glucose tolerance (IGT):

•( an area of uncertainty )represents an intermediate

category between normal and diabetes .

Fasting plasma glucose less than 126 mg/dl

2 hour plasma glucose>140 mg/dl but still less than
200 mg/dl during oral glucose tolerance test (OGTT)
 Impaired glucose tolerance (IGT):
- usually clinically asymptomatic
- a small percent with IGT revert to normal glucose
tolerance on subsequent tests
• at higher risk of developing type 2 diabetes and
macrovascular disease (atherosclerosis)
• not at increased risk for microvascular
complications
 Impaired fasting glucose
Fasting plasma glucose> 100 but still less than
126 mg/dl
normal 2 hour plasma glucose<140 mg/dl
during oral glucose tolerance test (OGTT)
Metabolic state between normal and DM
Increase risk of DM, cardiovascular disease.
 Gestational Diabetes
- During pregnancy, sensitivity to insulin decreases
(placental hormones affect glucose tolerance)
- beta cells may not be able to meet this increased
need for insulin gestational diabetes
- occurs in up to 14% of pregnancies
- This increases subsequent risk of developing type 2
diabetes
- Increased risk for perinatal mortality and neonatal
morbidity.
 Clinical features - Type 1
- Onset is variable.
- Classically, in younger age groups, the onset is acute and
insulin is needed for survival - generally present with a history
of polyuria, polydipsia, lethargy and weight loss over a period
of up to two weeks - many may present with ketoacidosis.
- Ketoacidosis - salt and water depletion; tachycardia;
hypotension; deep and sighing breath (usually smells of
acetone).
- In older age groups onset is more insidious - residual beta
cell function lessens risk of ketoacidosis at time of
presentation.
 Clinical features - type 2
- Usually occur in older age groups - especially obese (in 70%)
(however, incidence in child is assumed to be increasing due
to increased prevalence of childhood obesity).

- 50% have hypertension.

- Classical signs of thirst, polyuria, nocturia and weight loss
are not always present in Type 2 - often start with fatigue and
malaise
- Symptoms of hyperglycaemia are long standing and
generally mild.
- - Up to 20% may have one/some of the complications of
diabetes present at time of diagnosis.
 Link between hyperglycaemia and
complications

There are several structural mechanisms in which

the hyperglycaemia mediates tissue damage:
- Non-enzymatic glycation (glucose binds to proteins;
eg limited joint mobility, HbA1c)
- Oxidative-reductive stress (more free radicals
produced)
- sorbitol accumulates in cells.
 Functional consequences of
hyperglycaemia
- Haemodynamic disturbances (eg increased
capillary pressure)

- - Haemorrheological abnormalities (eg

increased blood viscosity; increased
coagubility)

- - Microvascular dysfunction
- Endothelial dysfunction
 Monitoring of glycemic control
- clinically,the pt signs &symptoms
- urine,much less used,no value in detecting
hypoglyceamia-depends on renal
thereshold??
- Blood glucose (home reagent strips&glucose
meter)helps to adjust the dose of insulin.
 Monitoring of glycemic control
1- glycated Hb
- Amount of HbA1 or HbA1c
- Used to assess long term glycemic control over
previous 6-8 weeks
- Should be monitored every 3 months in
diabetic patients
 Monitoring of glycemic control
- Glycation occures at a rate proportional to
blood glucose conc.
- Persistant reaction for life time of the cells
- Cauton in interpretation with pt with
decreased RBCS life span
 glycated Hb
R.R of HbA1 is 6-8% of HbA1
Normal <6%
(Aim or target in diabetic pt
less than 7%)
 Monitoring of glycemic control
2- fructoseamine
Glycated plasma proteins, including albumin
Short term glycemic control over previous 2-3
weeks
Much less widely used
 Monitoring of glycemic control
Others:
- Microalbuminuria
- lipid profile
- urine ketones
- plasma creatinin
 Metabolic complication of DM
1-hyperglyceamic coma with or without ketosis
2- lactic acidosis, (uncommon)
3- hypoglyceamic coma due to insulin excess
4- ureamia, due to diabetic nephropathy
 Ketotic hyperglyceamic coma
Clinical:
Thirst- polyurea- dehydration
Tachycardia -hyperventilation-vomiting
Abdominal pain-drowsiness-coma
Metabolic:
Metabolic acidosis-hypergluceamia-glycosuria-
ketonemia -ketonuria –hyperkalemia-
hypertriglyceridemia -heamconc.
 Ketotic hyperglyceamic coma
- May be presenting features of type1
- May develop in a known pt omits an insulin
dose(or inadequate)
Precipitating factors
Trauma, intercurrent infection, unusual :physical
or mental stress
 Ketotic hyperglyceamic coma
Pathogenesis:
- Insulin defficiency
- glucagon/catecholamine increased
Proteolisis-lipolysis-glycogeolysis-
gluconeogenesis(from the a.a)
….hyperglceamia
 Ketotic hyperglyceamic coma

-glucosuria ..osmotic diuresis..

- hyperventilation ..vomiting
(fluid depletion,)….renal hypoperfusion …
ureamia(RF uncommon)
 Ketotic hyperglyceamic coma

Lack of insulin…lypolysis..FFAs…ketogenesis
Vomiting..Acidosis..
Non-Ketotic hyperglyceamic coma
- Type2 DM
Severe hyperglyceamia-dehydration,no ketosis
&minimal acidosis.
 Oral Glucose Tolerance Test
(OGTT)
- Serial measurments of plasma glucose before
and after a specific amount of glucose given
orally
- Provide a standard method to evaluate glucose
tolerance
 Oral Glucose Tolerance Test
(OGTT)
Amount of given glucose:
- 75 g/kg for an adult
- 100 g/kg for a pregnant female
- 1.75 g/kg body wt for children (maximum
75 g)
 indications
Diagnosis of:
- - Impaired glucose tolerance
- - Impaired fasting glucose tolerance
- Gestational DM
- Evaluation of a patient with un explained
nephopathy , neuropathy or retinopathy with
a random glucose <140 mg/dl
 Oral Glucose Tolerance Test
(OGTT)
Normal criteria:
Fasting< 100 mg/dl
Peak < 170
2 hours < 140
All urine samples negative for glucose
 Oral Glucose Tolerance Test
(OGTT)
Abnormalities
1- DM
Fasting>126mg/dl
Or 2 hours >200 mg/dl
On more than one occation
( unless gross abnormalities)
2- impaired glucose tolerance
Fasting <126
2 hours > 140 but still <200
3- impaired fasting glucose
Fasting 100-126
2 hours < 140
4- renal glucosuria
Glucosuria at some point of the OGTT , usually
the peak
Inspite of
The plasma glucose level is still below the renal
threshold
Causes:
- idiopathic
- secondary:
- pregnancy
- metal poisoning: lead poisoning -
RTA
 Allimentary glucosuria
sharp rise of blood glucose to reach a peak
exceeding the renal threshold (>180 mg/dl)
Appearance of glucose in urine
2 hours is often much below the fasting level
Causes:
- post gasterectomy
- advanced liver disease
- thyetoxicosis
- some apparently healthy individuals
 Flat response
Plasma glucose fails to rise significantly after an
oral glucose load
The different between peak level and fasting
level is often <25mg/dl
 Flat response
Causes:
- malabsorption disorder
- insulinoma
- hypofunction of the endocrine gland glands
producing the insulin antagoniste.g.
hypopituitarism, cretinism, adrenocortical
hyposecretion
 Gestational DM
Screening:
All pregnant females >25 years
Or less in the presence of a risk factor
Done between 24-28 weeks of gestation
 Gestational DM
50 gm oral glucose is given as a loading dose
Ireespective to the time of the day or last meal
Plasma glucose measured at 1 hour
If plasma glucose is > 140 mg / dl confirm by
OGTT
 3-houres OGTT
Overnight fasting (8-14 hrs)
Measure fasting plasma glucose
Give 100 g glucose orally
Measure hourly for 3 hours
2 values must exceed the following:
 3-houres OGTT
Fasting: 95 mg/dl
1 hour: 180 mg/dl
2 hours: 155 mg/dl
3 hours: 140 mg/dl
 3-houres OGTT
If clinically suspicious situation repeat during the
third trimester
Dyslipidaemia-1
 Metabolism of cholesterol
• Cholesterol is cyclic and highly hydrophobic molecule
with several functions.
• •A half of cholesterol required per day comes from the
diet and another half is synthesized from acetyl-CoA.
• •In foods of animal origin, cholesterol is present as
cholesteryl esters. They are digested by cholesterol
esterase. Being in plasma membrane, cholesterol
modifies fluidity of the membrane. Cholesterol makes
plasma membrane more rigid.
• •In humans, cholesterol is the only substrate for synthesis
of steroid compounds: bile acids, active form of vitamin
D, and steroid hormones.
•
 Features of cholesterol synthesis
• Cholestrol synthesis occurs in smooth endoplasmic
reticulum of all types of cells containing nucleus.
• ••HMG-CoA reductase is a regulatory and rate
limiting enzyme. •
• The major lipid present in the plasma are fatty acids,
triglyceride, cholesterol & phospholipids
• TG consist of glycerol esterfied with three long chain
fatty acids, it is present in dietary fat & can be
synthesizes in liver & adipose tissues it is an important
energy substrate.
• Dyslipidaemia means
hypercholestrolaemia and
hypolipoproteinaemia particularly when
considering the individual at risk of CHD
because of high TC, low HDL(TC:HDL ratio).
 Epidemiology
• Lipid and lipoprotein concentrations vary among
different populations.
• There is increased risk of CHD with high serum
cholesterol.
• TG increases with age in men and women after the
age of 20 years.
Lipid transport and lipoprotein metabolism

• The major lipids in plasma (Cholesterol, TG,

phospholipids) transported in the form of
lipoprotiens. The main classes of lipoproteins;
chylomicrons, chilomicron remenants, VLDL,IDL, LDL,
and HDL.
• The protein components of lipoproteins are known
as apoproteins of which; apoprotein A-I,E,C and B
the most important.
• B has two forms; B-48, and B-100
• When dietary cholesterol and TG are absorbed from the
intestine they are transported in the intestinal lymphatic
as chylomicrons, which pass through blood capillaries in
adipose tissue and skeletal muscle where the enzyme
lipoprotein lipase (LPL) is located bound to endothelium.
• LPL is activated by apoC-II on the surface of the
chylomicron.
• The lipase catalyses the breakdown of TG in the
chylomicron to FFA and glycerol which then enter
adipose tissue and muscle.
• The cholestrol- rich chylomicron remenant is taken up by
receptors on hepatocyte membranes and in this way
dietary cholestrol is delivered to the liver and cleared
from the circulation.
• VLDL is formed in the liver, transports TG and
contains some cholesterol. The TG content of
VLVL is removed by LPL and forms IDL particles.
• IDL acquire cholesterol esters from HDL under
the influence of the enzyme lecithin-cholestrol
acyl transferase (LCAT)
• IDL transported to the liver or further modified to
loose TG and apoprotein E1 and become LDL
particle ,which is the major cholesterol-carrying
particle in plasma.
• LDL provides cholesterol, to those cells that require it,
and also the main lipoprotein involved in
atherogenesis.
• For reasons that are not clear but probably related to
minor trauma, or hypertension, the arterial
endothelium becomes permeable to lipoproteins,
monocytes migrate through the permeable
endothelium and engulf the lipoproteins, this results
in the formation of lipid-laden MQ that have principal
role in the development of atherosclerosis.
• While VLDL and LDL are considered the
bad lipoproteins ,the HDL is the good
antiatherogenic lipoprotein.

• HDL transports cholesterol from peripheral

tissues to liver for excretion.
 Exogenous pathway
• Exogenous pathway; in the intestine fatty acids &
cholesterol are produced by digestion of food, some
cholesterol is derived from the bile. In the intestine
the lipids are re-esterified to form cholesterol esters &
TG& are backed into chylomicrons, which carried to
lymphatic & then to circulation through thoracic duct.
the enzyme LPL hydrolyses TG into glycerol & FA. so
outcome is to deliver TG to adipose tissue& muscle&
cholesterol to the liver.
 Endogenous pathway
• The liver is principal site of endogenous lipid synthesis. some
cholesterol goes into the bile & some is secreted in the blood
as VLDL , TG of VLDL are removed by LPL in fat & muscle, the
remaining VLDL contains both cholesterol & TG & is known as
IDL. Some of IDL is rapidly taken by the liver& the rest is
converted to LDL by removing of TG &Apo-E.
• LDL is the major lipid in circulation which provide cholesterol
to cell membrane & steroid synthesis
• Most of LDL is removed by hepatocytes.
• HDL is synthesized mainly in the intestine &
hepatocytes. HDL also takes up cholesterol
from cells & other lipoproteins. So it is imp. In
transferring cholesterol from tissues to the
liver.
 Classification of lipoproteins
• There are four major classes of lipoproteins classified on the bases
of their densities which increases from chylomicrons (lowest) to
HDL as:
• 1- chylomicrons which carry exogenous dietary fat from the gut to
the peripheral tissues.
• 2- VLDL; which carry endogenous TG from the liver to tissues.
• 3-LDL; which carry cholesterol from liver to peripheral tissues.
• 4- HDL; carry cholesterol from peripheral tissues to liver where it
can be excreted.
• IDL only present in pathological conditions it come from
metabolism of VLDL, it is precursor of LDL.
 Lipid study is mandatory in;
• 1-CHD (coronary heart disease)
• 2- family history of premature CHD (occuring
below 60 years)
• 3-stigmata of hyperlipidemias; tendon
xanthomata, corneal arcus.
• 4-lipaemic plasma.
• 5-risk factors of CHD ; DM & hypertension.
Dyslipidaemia-2
 Classification of primary hyperlipoproteinemias

disorder Fridrickson Lipoptn [Link] T.G

s class abnormalit
y
LPL I Chylomic N or
defeciency
Familial IIa LDL N
hyper
choles
Dysbeta III IDL and
lpiop chylomic
remnant
Familial IV VLDL N or
hyper TG
Familial IIa or IIb or VLDL/LDL N or N or
combined IV
hyperlipo
Type V V VLDL and N or
hyper lipop chylomic
Hyper HDL N or N
alpha lpo
 WHO classification of
hyperlipidaemias
• 1- type I; increased Chylomicron ,TG.
• 2- type IIa: increased LDL & cholesterol.
• 3-type IIb: increased VLDL, LDL, cholesterol& TG.
• 4-Type III; (broad B band); increased
cholesterol& TG.
• 5- type IV; increased VLDL,TG & cholesterol.
• Type V: increased Chylomicron, VLDL,
cholesterol& TG.
 Aetiology
• Dyslipidemia is classified into primary and secondary
dyslipidaemia.
• Genetically determined dyslipidaemia (familial,
primary) occurs In 60% of cases. and classified to;
1-the primary hypercholesterolemia in which
cholesterol is raised.
• 2-the primary mixed (combined) hyperlipidaemias in
which both cholesterol and TG are raised.
• 3-The primary hypertriglycerdaemia
 Primary hyperlipidemias
• There is many inherited lipid disorders;
• 1- familial hypercholesrolaemia;
• mostly heterozygous, different mutations affect LDL
synthesis, transport causing high levels of cholestrol.
• Characterized by coronary artery disease in childhood.
(less than 40 years).
• The affected person develop signs of cholesterol
deposition such as tendon xanthomas, and xanthelasma
(lipids in the eye lid) in their third decade.
 1- familial hypercholesrolaemia (cont,)

• Homozygous state are rare and associated

with absence of LDL receptors, Pt present
with MI in children.
• 2-Familial combined hyperlipidaemia;
• There is excessive synthesis of VLDL associated with
development of atherosclerosis before 60 year of age.
• 3-familial type III hyperlipoproteinaemia;
• characterized by accumulation of chylomicron and
VLDL remnant that failed to get cleared at normal
range by hepatic receptors .Total cholesterol and TG
both are elevated and accompanied by both corneal
arcus and xanthelasma, also it cause premature
atherosclerosis.
• 4-familial lipoprotein lipase defiency;
autosomal recessive condition characterized
by defiency of the enzyme LPL causing failure
of clearance of chylomicron, causing
hypertriglycerdaemia and chylomicronaemia.

• Pt present in childhood with eruptive

xanthomata ,lipaemia retinalis, splenomegaly
& recurrent abdominal pain due to
pancreatitis . there is increased susceptibility
to atherosclerosis.
• 5-familial apolipoprotein C-II deficiency;

• In the heterozygous state it is associated with

reduced level of apolipoprotein C-II, the activator
of lipoprotein lipase,
• but in homozygous state there is complete
absence of apolipoprotein C-II,
• despite normal level of LPL it can not be
activated,
• so there is hypertriglycerdaemia and the Pt may
develop acute pancreatitis.
• 6-lipoprotein (a); it is major genetically
inherited determinant of CHD.
• it play role in both atherogenesis and
thrombogenesis. it is structurally similar to
plasminogen and may competitively bind
to fibrin and impair fibrinolysis, so
increased levels leads to increase LDL, and
so atherogenesis.
 Secondary hyperlipidemias
1- obesity
2- excessive alcohol intake
3- D.M
4- hypothyroidism
5- nephrotic syndrome
6- chronic renal failure.
7- cholestasis.
8- drugs; thiazides, B-blockers, oestrogen,. androgen,
glucocorticoids,vit.A derivatives, oral contraceptives.
9-inappropriate diet
10-hepatocellular diseases.
• DM; type I;HDL may be high but not protective
against atherosclerosis for unknown reason
• In type II DM, Pt has increased TG and decreased
HDL, high LDL, treatment with statin is
recommended if LDL is high.

• hypothyroidism.; can cause combined

hyperlipidemia or severe hypertriglycerdaemia

• Chronic renal failure; dyslipidaemia due to

reduced lipoprotein lipase activity.
• Nephrotic syndrome; dyslipidaemia due to
increased production of apolipoprotein B-100
and associated high LDL.

• Obesity; chronic excessive intake of calories lead

to increased TG and reduced HDL.

• Alcohol ; the high calorie content of beer and

wine may be a cause of obesity. In addition
alcohol increases hepatic TG synthesis.
 Management

• Risk assessment;
• Assess the risk fully; age, gender, smoking
habit ,DM, systolic BP, TC/HDL ratio.
 Lifestyle modification
• Stop smoking
• Eat more starchy carbohydrates, fruits and
vegetables.
• Less saturated fat, sugar and salt.
• Reduce weight if obese
• Increase physical activity
• Reduce alcohol intake if excessive.
 Non-lipid intervention

• Treatment of hypertension.
• Aspirin.
• Treatment for diabetes.
Exclude underlying cause of dyslipidaemia

• Liver function tests.

• renal function tests.
• Urine analysis.
• TSH
• Fasting glucose.
• Check prescribed drugs for side effects.
 Lipid lowering therapy
• There are four main classes of lipid
lowering agents;
• 1-HMG-CoA reductase inhibtor.(hydroxy
methyl glutaryl Co enzyme A reductase)
(statins)
• 2-fibrates.
• 3-anion exchange resins
• 4-nicotinic acid and derivatives.
• Agent such as soluble fiber and fish oils have
been used to reduce lipid levels.
• The choice of lipid lowering agent depend on
the underlying Dyslipidemia.
Gastric Dysfunction
The stomach is famous for its secretion of acid,
but acid is only one of four major secretary
products of the gastric epithelium, all of which
are important either to the digestive process
or to control of gastric function
1-Mucus:
Mucous cells are most abundant epithelial cells They
secrete a bicarbonate-rich mucus that coats and
lubricates the gastric surface, and serves an
important role in protecting the epithelium from acid
and other chemical insults.
2-Acid:
Hydrochloric acid is secreted from parietal cells into the
lumen where it establishes an extremely acidic
environment.
Acid is important for:
- - activation of pepsinogen
- - inactivation of ingested microorganisms .
3-Proteases:
Pepsinogen, an inactive zymogen, is secreted into
gastric juice from both mucous cells and chief cells.
Once secreted, pepsinogen is activated by stomach
acid into the active protease pepsin, which is largely
responsible for the stomach's ability to initiate
digestion of proteins.
4-Hormones: The principal hormone secreted from the
gastric epithelium is gastrin, a peptide that is
important in control of acid secretion and gastric
motility.
 Stimuli for Gastric Secretion
1-Neurogenic impulses from the brain transmitted via
vagus nerve (initiated by sight, smell, taste, or
anticipation of food).

2-Distention of stomach with food or fluid.

3-Contact of stomach with food or fluid.

4-Gastric hormone: the most potent stimulus.

 TESTS OF GASTERIC FUNCTION
1-To detect acidity (achlorhydria)
------pernicious anemia in adults.

2-To detect marked hypersecretion-----gastrinoma (Z-

E-syndrome).

N.B : otherwise, borderline test results are of little

diagnostic value due to the wide overlap among
healthy and diseased patients:
 Acid secretion studies are rarely of value in
diagnosis of PU??
Gastric ulcer: Normal secretary volume and acid
output.
Duodenal ulcer: Increased volume and acid output but
still considerable overlap with N range.

They may be used to indicate how much acid is

secreted to determine the type of surgical procedure
required for treatment of PU or to indicate the
adequacy of vagotomy.
 A. Evaluation of Gastric Acid Secretion
Pentagastrin Test
Principle
Pentagastrin is a synthetic pentapeptide with
similar action to gastrin molecule : it is a
potant stimulator of gastric acid secretion. It
assesses acid secretion under basal and
maximally stimulated conditions.
Indications
Investigation of patients with suspected
gasterinoma (Z-E syndrome).
Procedure
- overnight fast of 10-16 hours
- Aspirate the resting juice.
- Collect the basal juice over next 60 min with patient
at rest.
- - Inject pentagastrin
- - collect the post-pentagastrin secretion for 60min as
4 separate 15min specimens.
Measure the volume, pH, and acid content. Not the
presence of bile or blood.

*peak acid output = rate of acid secretion in mmol/h

derived from the 2 adjacent 15min samples with
maximum output.
 Interpretation
increase acid output in ZE syndrome.

Achlorohydra in pernicious anemia

All intermediate values are of little diagnostic

significance due to wide overlap.
 PLASMA GASTRIN

Plasma gastrin reflects the rate of gastrin

secretion.
Gastrin is a polypeptide released by cells in
antral and duodenal mucosa.

It is a potent stimulator of gastric acid

production.
It is also trophic to the gastric mucosa.
 PLASMA GASTRIN(cont,)
Physiological stimuli for its release:
*Distention of stomach and presence of small
peptides and aminoacids released by protein
digestion (most potent).

*A fall in gastric (H+) due to food or HCO3 in

stomach.

Fasting results in increase gastrin

 INDICATIONS:
Plasma gastrin, SHOULD be measured in patients with
persistent, recurrent, or multiple peptic ulceration with
provisional diagnosis of GASTRINOMA and with increase acid
secretion already demonstrated.
SAMPLING:
Gastrin is very labile.
Blood samples should be:
*taken after overnight fast.
*in heparinized tube
*containing aprotinin (protease inhibitor)
*rapidly centrifuged within 15min (serum or plasma)
*immediate freezing
*discard samples with any visible hemolysis
 INTERPRETION:
N serum gastrin: males<100ng/L,
female<75ng/L.
Increase fasting serum gastrin:
*with hyperacidity:Gastrinomas
------- increase 2-2000XN(>200ng/L)
------- conc. >1000ng/L DIAGNOSTIC
Decrease fasting serum gastrin: occurs in all
diseases causing hyperacidity (e.g. DU)
EXCEPT in gastrinoma.
 ZOLLINGER-ELLISON SYNDROME
This syndrome is due to GASTRINOMA
(neoplasia of pancreatic or gastric gastrin
producing cells).
Increase gastric production results in chronic
hyper secretion of gastric acid results in
multiple and recurrent PU, sometimes
diarrhea and steatorrhea (increase H+in
intestine ------inhibits pancreatic lipase).
DIAGNOSIS:
Diagnosis is usually made by finding grossly
increase fasting serum/ plasma gastrin and by
excluding other causes of increase gastrin

In 30%:N/slightly increase -----Acid secretion

studies

In 15%: slightly increase gastrin and acid

secretion -----secretin test
 SECRETIN TEST
PRINCIPLE:
Secretin is a hormone secreted by the duodenum that
stimulates pancreatic secretion of HCO3, enzymes
and insulin.
It also inhibits gastrin release and gastric acid secretion.
INDICATION:
Investigation of patients with provisional diagnosis of Z-
E syndrome for DD between antral G-cell hyperplasia
and gastrinoma(Z-E)
PROCEDURE:
overnight fasting
Secretin injection
blood samples for gastrin assay collected :
*5min before
*at time of secretin injection
*2, 5, 10, 20 and 30min after injection.
INTERPRETION:
In gastrinoma-----at least 2 folds increase
In G-cell hyperplasia-----decrease or no change
 UREA BREATH TEST

PRINCIPLE:
H. pylori is present in the gastric mucosa in nearly all
patients with DU and in majority patients with non-
malignant GU.
The organism has increased urease activity.
It stimulates acid production by converting urea----
NH3+CO2
Urease activity can be determined directly in a gastric
biopsy or indirectly by a breath test.
PROCEDURE OF BREATH TEST:
Overnight fast
C14 urea given orally '
collect breath samples at frequent intervals
Determine C14 content of the sample.

INTERPRETATION:
Patients infected with [Link] have increase excretion
of 14CO2.
Test is NOT diagnostic but can be monitor the effects of
antibacterial treatment in these patients.
 Malabsorption syndrome
• - can be a result of intestinal, pancreatic,or
hepatic dysfunction.
- Can be excluded by simple blood tests
- If obvious clinically (steatorhea, +wt loss) test
add nothing to diagnosis
- Once diagnosed investigation of the cause:
biochemical,histological,radiological data are
needed.
 Clinical features
Diarrhea, steatorhea, distention, abdominal
discomfort
Aneamia, glossitis, osteomalacia, ricketes,
edema, wt loss, growth failure.
 causes
- Ch. pancreatitis,cystic fibrosis.
- Bile salt deficiency, biliary obs-hepatic
diseases.
- Bacterial growth+ impaired mixing of food
after gastric surgery,
 Simple tests for diagnosis
- [Link],
- calcium,
- CBC
- s,iron,
- vitamin B12,
- folate,
Pancreatic disorders
 PANCREATIC SECRETION
The exocrine function of the pancreas is and secretion of
pancreatic juice that is rich in enzymes and bicarbonate.

Enzymes :
-amylase, lipase and
- proteolytic enzymes (trypsin, chymotrypsin,
carboxypeptidase A, B, phospholipase A, ribonuclease,
elastase, and collagenase)

Normal pancreatic juice is:

Colorless and odorless
pH 8-8.3
 NORMAL PANCREATIC PHYSIOLOGY

The pancreas secretes 1.5 liters of enzyme-rich fluid

every day for the digestion of fats, starch, and
protein.
Normal pancreatic juice is clear, colorless, isotonic, and
alkaline.
The composition of pancreatic juice:
In the fasting state, pancreatic fluid is protein-rich and
has a bicarbonate concentration of 80 mmol/L.
Stimulation of the pancreas after a meal increases the
flow of water and the bicarbonate concentration of
pancreatic juice. A large volume of alkaline, enzyme-
rich fluid enters the duodenum to neutralize gastric
chyme for optimal digestion.
 NORMAL PANCREATIC PHYSIOLOGY

Pancreatic secretion is controlled by hormonal and

neuronal mechanisms.
regulatory hormones are secretin and cholecystokinin
(CCK).
Secretin is released from the duodenal mucosa in
response to the presence of acid in the duodenum
Secretin primarily stimulates the release of bicarbonate
and water from the interlobular duct cells and causes
a gradual rise in the flow of pancreatic fluid through
the ducts and a typical pattern of electrolyte
secretion
Secretin regulation of bicarbonate secretion
 ACUTE PANCREATITIS
Acute pancreatitis is sudden inflammation of the pancreas that
may be mild or life threatening but that usually subsides
(GENERALLY REVERSIBLE).

Gallstones and alcohol abuse account for almost 80% of the

hospital admissions for acute pancreatitis.
As well as, may be due to vascular or infective causes.
25% 0f cases are idiopathic.

About 1½ times as many women as men experience acute

pancreatitis caused by gallstones.
 pathogenesis
Normally, the pancreas secretes pancreatic fluid through the pancreatic duct
to the duodenum. This pancreatic fluid contains digestive enzymes in an
inactive form and inhibitors that inactivate any enzymes that become
activated on the way to the duodenum.

Blockage of the pancreatic duct by a gallstone stuck in the sphincter of Oddi

stops the flow of pancreatic fluid. Usually, the blockage is temporary and
causes limited damage, which is soon repaired.

If the blockage continues, activated enzymes accumulate in the pancreas,

overwhelm the inhibitors (proteolysis, lipolytsis, oedema, heamorrhage
and necrosis), and begin to digest the cells of the pancreas, causing
severe inflammation.
ACUTE PANCREATITIS
 LAB DIAGNOSIS
Confirmation of clinical diagnosis mainly depends on plasma amylase activity
measurements.

Plasma lipase and trypsin are also increased, but are rarely measured
routinely for the inv, of pt with acute abdomen.

Other chemical tests include serum calcium which may be considerably

decrease in sever cases (formation of insoluble Ca salts with free fatty
acids in areas of fat necrosis and increase Ca influx into cells due to
damaged cell membranes),

Plasma metheamalbumin is sometimes increase in sever cases ( of no

diagnostic value).
Liver enzymes- alk ph –bilirubin : (gall stone)
 Serum Amylase
Indication: in diagnosis of acute pancreatitis and distinguish it
from other causes of acute abdomen.

Serum amylase levels in pancreatitis vary depending on the

severity of the disease.

During uncomplicated cases, the serum amylase level starts

increasing from two to 12 hours after the onset of symptoms
and peaks at 12 to 72 hours (>5 XN).

It usually returns to normal within 3-5days

 Serum Amylase (cont,)
The advantages of amylase testing:
It is quickly performed, simple, widely available and inexpensive.
75 to 92 % of diagnostic sensitivity for ac pancreatitis i.e. 25-8 % pt have
normal amylase.
Raising the threshold to at least three times the upper limit of the normal
reference value can increase the specificity of the serum amylase and
lipase levels in diagnosing acute pancreatitis.
Disadvantage:
It is relatively non specific (specificity 20 to 60 %).
Levels>5XN may also occur in other diseases as mesenteric infarction, acute
biliary tract disease, acute parotitis and afferent loop syndrome.
Moderate increase may occur in acute abdomen as perforated peptic ulcer ,
morphin injections, drugs causing spasm of sphinciter of Oddi as well as in
patients with diabetic ketoacidosis
Determination of p-isoamylase activity is a more sensitive and
specific than total amylase for diagnosis of acute pancreatitis.

Urinary amylase increased in acute pancreatitis is more

prolonged (7-10days).It has NO advantage over serum
amylase assay is as a part of investigation of
macroamylasemia (persistent moderate increase in serum
amylase with decreased renal clearance of macroamylase).

Amylase/creatinin ratio (ACCR): to correct for decreased

glomerular function and for differential diagnosis of
macroamylasemia from other causes of increase serum
amylase . Normal reference range 2-5%. In acute pancreatitis
>5 %( usually 7-15), in macroamylasemia<2%.
 Lipase
Lipase levels increase within four to eight hours of the onset of
clinical symptoms and peak at about 24 hours.

Levels decrease within eight to 14 days.

The specificity (50 to 99 percent) and sensitivity (86 to 100

percent) of lipase measurements are better than those of
amylase measurement, particularly in detecting alcoholic
pancreatitis.

The specificity of lipase measurement, as well as amylase

measurement, may be improved by raising the threshold to at
least three times the upper limit of the normal reference
values.
 CHRONIC PANCREATITIS
Chronic pancreatitis is long-term (chronic) inflammation of the
pancreas that CHARCTERIZED by persistent and often
progressive lesion leads to irreversible permanent damage of
exocrine parenchyma, fibrosis and in late stages, destruction
of endocrine parenchyma .

50% of patients with chronic pancreatitis suffer from attacks of

acute pancreatitis.

Failure to secrete adequate amount of pancreatic enzymes may

not occur until the disease is advanced.
Because the pancreas is the major source of amylase, lipase and
proteolytic enzymes, therefore a significant decrease in
pancreatic function -----decrease absorption of starch
(amylorrhea), fats (steatorrhea, and protein (creatorrhea
 DIAGNOSIS
There is no single test that can be used to diagnose chronic
pancreatitis. There is long-lasting abdominal pain or signs that food
is not being properly absorbed, such as weight loss or greasy stools,
ask about alcohol use, and other factors that increase risk of chronic
pancreatitis and other digestive problems.
Blood tests to check for high levels of amylase and lipase. These
enzymes typically are elevated in people with acute pancreatitis and
in many people with chronic pancreatitis, especially during a flare-
up of symptoms. But are of limited value because of markedly
reduced acinar cell mass and mild inflammation may not increase
enzymatic activity.
Noninvasive imaging tests as US, CT and magnetic resonance
cholangiopancreatography (MRCP), which evaluates the ducts
without requiring an endoscope or contrast material this test is not
as accurate a test as the ERCP.
In case of intermediate results, although pancreatic disease is
suspected on clinical grounds, we resort to tests measuring exocrine
function of the pancreas.
 Tests of exocrine pancereatic function
INVASIVE TESTS (direct):

They require gastro-intestinal intubation to assess pancreatic

secretion after direct stimulation
Either ; intraluminal by Lundh test meal or intravenous by IV
injection of hormones as secretin/CCK.

Collected specimen of duodenal content are assessed for :

*total volume
*amount or conc. of bicarbonate
*rate of enzyme secretion

These tests are more sensitive and specific.

 INTERPRETATION

IN HEALTHY SUBJECTS:
The max post-secretin secretory rate is >2kg BW/h
Bicarbonate increase >75mmol/L
Enzyme activity is variable

IN CHRONIC PANCREATITIS
Most cases show decrease enzyme activity and bicarbonate
conc. before any obvious reduction in volume.

IN PANCREATIC CARCINOMA
All 3 variables decrease but marked decrease in volume of the
juice is characteristic feature of cancer head of pancreas
producing obstruction. Tumors in the tail of the pancreas do
not produce abnormal results in this or similar tests.
 INTERPRETATION(cont,)

LUNDH TEST MEAL:

After stimulation of pancreatic secretion by a meal containing
carbohydrates, protein and fat, the duodenal contents are
collected for 2 hours and enzyme activity is measured.
Decrease enzyme activity indicates pancreatic exocrine
insufficiency.

LACTOFERRIN IN PANCREATIC JUICE

An iron-containing glycoprotein secreted by the pancreas.
Increase in chronic pancreatitis but normal in pancreatic
carcinoma
 Tests of exocrine pancereatic function
NON INVASIVE TESTS (indirect) more widely used:

They require no intubation. They are simpler, cheaper and more preferred.

They are based on the fact that proper pancreatic function is essential for
normal intestinal absorption of certain substances.
They are less sensitive and specific than invasive direct methods and less
reproducible.

A great overlap in results exists between normal and abnormal due to the
large functional reserve of the pancreas and the activity of micro-
organism and intestinal enzymes.

False negative results are obtained in early and mild cases until 50% of
pancreatic cells are lost.
False positive results occur in celiac disease and spure (increase intestinal
motility).
 BT-PABA-(14C)-PABA TEST:
PRINCIPLE
It is indirect test to assess pancreatic response to stimulation by a meal
(Lundh test meal).
Pancreatic chymotrypsin specifically hydrolyses the synthetic peptide benzoyl
tyrosyl -P=aminobenzoic acid (BT-PABA)====PABA-----
INTESTINE(absorbed)-- liver(metabolized )------- kidney (excreted urine)

PROCEDURE:
Patients are given BT-PABA + isotopically labelled (14C)-PABA + test meal (to
stimulate the pancreas)
(14C)-PABA is added to correct for individual variation in absorption,
metabolism, and excretion of PABA after release in the intestine.
Collect urine over 6 hours.
Measure urinary PABA and 14C contents
Express results as % of their oral dose
Calculate the PABA: 14C excretion index.
Reference range :0.84-1.16
 INTERPRETATION
In chronic pancreatitis ------hydrosis of BT-PABA is impaired ------
decrease excretion index
Results correlate with the CCK=PZ and Lundh tests.

Though less specific and less sensitive than direct stimulation

tests, they are relatively easy to perform, non invasive, and
suitable for inv of outpatients.
It is contraindicated in children, pregnancy, and in renal failure.
Falsely abnormal results are obtained in liver and small intestinal
diseases if (14C)-PABA is not used.
 Carcinoma of pancerease
- often late presntation as:
- - Metastsasis
- - Ostructive jaundice (cancer head)
- malabsorption
Investigated by: tumour markers
CEA, CA19-9
 CYSTIC FIBROSIS
Every day when she wakes up, Lisa begins to deal with a
condition she's known all her life - cystic fibrosis while still in
her pajamas, her parent's clap her back and chest for at least
20 minutes to help clear her lungs of the thick mucus that
sometimes makes it difficult for her to breathe.
At school, Lisa coughs a lot, so she keeps a box of tissues on her
desk just in case she coughs up mucus and needs to spit it
out. In gym class, she participates in sports but often gets
tired easily. At lunchtime, Lisa takes pills to help her digest
her food and get all the vitamins she needs, which helps her
keep up her strength to deal with cystic fibrosis.
CYSTIC FIBROSIS
Cystic fibrosis (CF) is an inherited autosomal
recessive disease that characterized by
dysfunction of exocrine glands throughout the
body results in abnormal electrolytes and
mucous causes the body to make thick, sticky
mucus.

• This causes problems in two major areas: the

lungs and the digestive system.
Healthy lungs produce mucus, which protects the airways and
makes it easier to breathe. But for a person with CF, the
mucus is thick and sticky and can clog up the lungs.
This creates a place where bacteria can easily grow - and
bacteria cause infections.

- not only the lungs :Mucus-producing cells line the digestive

tract, including the stomach, intestines, liver, and pancreas.

- The pancreas produces enzymes that help digest food and

hormones that help absorb sugar. When thick mucus in the
pancreas clogs up the narrow passageways, it can make it
difficult for people to digest food and get all the vitamins and
nutrients they need
Cystic fibrosis affects more than 1/1600 live births
(relatively common). It can be mild or severe,
depending on the person. To make normal mucus,
the body needs a special protein. This protein is
defective in cystic fibrosis, producing the thick, sticky
mucus that causes problems for people with CF.
What Causes CF?
CF is an inherited disease, which means that it's passed
down from parent to child. Someone who has CF was
born with it. Mutations in the CFTR gene cause cystic
fibrosis
Although someone with cystic fibrosis is born with it, it
isn't always obvious at birth. It may take a while for
symptoms to develop.
Doctors may suspect that a baby has CF if:
In newborn------intestinal obstruction (mucous plug
blocks the bowel lumen).
In children: he or she coughs a lot and gets a lot of lung
infections (chronic pulmonary disease, repeated
pneumonia). The baby also might have unusual large,
bulky bowel movements or may not gain weight as
expected.
In adults------exocrine pancreatic insufficiency and
malabsorption (duct obstruction---auto-activation of
pooled enzymes----destruction of pancreatic tissue
25% 0f CF).
 DIAGNOSIS:
It relies on a triade:

Abnormal sweat electrolytes,

Presence of pancreatic and bronchial abnormalities
Positive family history

SWEAT CHLORIDE TEST:

This is the single and most accepted diagnostic tool.
In CF Na ions are improbably resorbed.
Inborn Error of Metabolism
 Inborn error of metabolism
Diseases as a result of gene mutation either
prevents synthesis of a protein or cause
production of abnormal protein.
In majority of cases, ptn is an enzyme
Diagnosis depends on:
- clinical features

- Measurements of conc. of metabolite, or

enzyme precursor

- Response to ttt
An inborn error is suspected when:

 a previous neonatal death is unexplained

 the parents are biologically related,
 Diagnosis of Inborn error of metabolism

1- Examination of a sick infant or child (clinically)

 The condition is suspected when infant or
young child demonstrates clinical symptoms
of persistent vomiting, failure to thrive, or
neurological or liver abnormalities.
 symptoms appear when feedings are
changed or the condition improves when
food is withheld and the infant or young
child maintained on a glucose saline drip.
2- Neonatal screening:
 Most screening programs have been directed at early
detection of PKU (also congenital hypothyroidism) Test
should be highly sensitive.

 Individuals should follow a normal diet for at least 24 hrs.

before a specimen is collected.
3- Prenatal diagnosis:
It is important when a mother previously has given
birth to a child with a sever inherited defect.
Techniques are amniocentesis or chorionic villus
sampling
Early ttt or termination is indicated according to
abnormality
 Techniques available for prenatal
diagnosis
Maternal plasma screening
U/S
Amniocentesis
Fetoscopy
Chorinic villus sampling
 Treatment of inborn error of
metabolism
- no ttt
- replacement of the missing product
- dietary modification
- gene therapy
 Disorders of Amino Acid Metabolism
 They are usually inherited.

 Block or deficiency of a key enzyme in their metabolism.

 AA of particular importance include, phenylalanine,

tyrosine, cystine, etc.
 Amino Aciduria
 AA in blood are filtered through the glomerular
membrane but are normally reabsorbed in the renal tubules
by an active process.
 Amino acidurias may be primary or secondary. Primary is
due to an inherited enzyme defect. It is also called an inborn
error of metabolism.

 Secondary aminoaciduria is due to disease of an organ

such as liver, generalized renal tubular dysfunction .
 Types of aminoaciduria
1- Over flow aminoaciduria (when plasma level exceeds
renal threshold).

2- Renal amino aciduria (congenital or acquired defect in

renal transport mechanism).
Disorders of Phenylalanine Metabolism:
 Hyperphenylalaninmia

 Deficiency of phenylalanine hydroxylase.

 Classic PKU:
 1:10,000 neonatal incidence rate
The enzyme phenylalanine hydroxylase is almost totally
absent..

 Increased phenylalanine in blood , urine and CSF.

Symptoms of PKU:
 Untreated PKU causes sever mental retardation.

 Affected infants appear normal at birth, and the earliest

symptoms are usually delayed development, feeding
difficulties, and vomiting, sometimes sufficiently sever to
suggest pyloric stenosis.
 In some children, an unusual but characteristic musty odor
may be noted in urine or sweat
 Without treatment, irreversible retardation progresses.

 Older patients frequently show seizures

Treatment of PKU:
 PKU is both a genetic and a nutritional disease.

 A life time low-phenylalanine diet is the current treatment

of choice.

 Once diagnosed, dietary restriction is initiated before the

onset of brain damage
Maternal PKU:
 Occasionally occurs in adult phenoketonuric pregnant
females.

 More cases of this disorder are arising as children treated

for PKU become adults.

 High maternal levels of phenylalanine cross the placenta

resulting in cardiac defects, intrauterine growth retardation,
anencephaly and mental retardation of the fetus.

 Mothers should follow a restricted diet before conception

and throughout pregnancy.
Tyrosinemia (1:100,000)
 Tyrosine is essential for protein synthesis and serves
as a precursor for thyroid hormones, melanin and
catecholamines.

 Tyrosinemia is either due to deficiency in the

enzyme fumaryl-aceto-acetate hydrolase (type I) or
deficiency in the hepatic enzyme tyrosine amino-
trasferase (type II).
 Alkaptonuria

 It is a rare hereditary metabolic disease resulting from

deficiency of HGA oxidase in the major catabolic pathway
that converts tyrosine to fumarate and acetoacetate.

 Reduced enzyme activity causes accumulation of HGA

in cells and body fluids.
  HGA binds to collagen in cartilage, intervertebral discs and
other connective tissue. This results in degenerative arthritis
and pigmentation of cartilage (1st appear in the ear).

 A urine sample from affected individual darkens with time,

on exposure to air or on addition of alkali.

 Alkaptonuria usually is not diagnosed until middle age,

when arthritis and pigmented ear lobule lead to suspicion.

 But it can be diagnosed in neonates if the dark stain in an

unwashed diaper is noticed and investigated.
Cystinuria :
 Classic cystinuria is the most common inborn error of
AA transport. This disease is characterized by massive
urinary excretion of cystine.
 Because cystine is the least soluble of the naturally
occurring AAs, its over excretion often leads to the
formation of cystine calculi in the urinary tract.
 Approximately 1- 2% of all urinary tract stones are
composed of cystine.
 Treatment involves ingestion of large amount of water,
and by making the urine alkaline.
Analysis of AA :
This include screening tests, quantitative tests and specific
tests to identify individual AA

Specimen requirements : Should be valid and

representative.

 Patient should follow a normal diet for 2-3 days before

sample collection.
 Blood & urine samples should be collected simultaneously.

 Heparinized plasma is preferable to serum and other

anticoagulants.
Screening tests:
 Guthrie test :
(Semi quantitative microbiological assay)

Using a strain of Bacillus subtilis

Growth is only seen if excess Phenylalanine is present
(Or the AA of interest)
 In the presence of elevated concentration of the AA of
interest, the effect of growth inhibitor is diminished or
overcome and zone of bacterial growth is observed.

 The test system is designed to show growth only when

the concentration of the AA of interest exceeds its upper
reference limit.
 Quantitative tests:

HPLC, ion exchange liquid chromatography

etc…
TUMOR MARKERS
 Content
Definition.

Classification of tumor marker.

tumor marker in cancer management.
Properties of ideal tumor marker.
Oncofetal antigen.
Placental Proteins.
Enzymes as tumor marker.
Hormones.
Future and Development.
References.
 kEY TERMS
• Cancer. • Protooncogenes
• DNA INDEX (DI) • Staging
• Neoplasm • Prevalence ,Predictive
• Onco fetal Antigen value
• tumor associated • tumor marker.
Antigen.
• tumor specific Antigen
 Cancer
Introduction:
•Account about 23% of all death annually .

•Although cancer mortility rate has remained relativel constant for several
decade
•Cancer become the second only to heart disease as amajor health issue in
USA.
•There are more than 50 types of cancer in humans with 54% of new cancer
case occuring in lung_bronchus,colon –rectum .,breast ,prostate and uterus.
•Certain cancer type predominate in certain gender (sex) ie
•Lung ,colon ,prostate ,urinary bladder cancer are commonly seen in men .
•Whyle , uterine ,breast cancer commonly seen in women .
• strategy for controlling cancer :
• 1/ prevention by identification and elemination of cancer causing
element or factor.
• 2/ early detection of cancer.
• 3/ Devolopment of effective treatment.
• So as to prevent from all surrounding carcinogenic
element could be difficult (if it not possible) so the
promossing approach to control cancer is early
diagnosis.

Biophysical methods eq..

• conventional radiograph .
• nuclear medicine
• rectilinear scanner
• ultrasonograph
• computed tomograph
• magnetic resonance imagining
• Clinical lab-testing for tumor marker can be useful in :
• ediagnosis.
• staging disease progression .
• monitorig response to therapy .
• detection of disease recurrence.
 Anumber of methods are currently available to detect cancer including:
Biophysical methods eq..
• conventional radiograph .
• nuclear medicine
• rectilinear scanner
• ultrasonography
• computed tomography (CT scan)
• magnetic resonance imagining (MRI)

•Clinical lab-testing for tumor marker can be useful in :

• diagnosis.
• staging disease progression .
• monitoring response to therapy .
• detection of disease recurrence.
 Definition and classification
• rtumor marker can define as :Abiological substance synthesize by cancer
cels or by host tissue in response to cancer.

• Sites and location:

• Circulation .
• body fluid cavity.
• cell membrane.
• cell cytoplasm.
• nucleus .

• The differ in location The differ in methods use for detection.

how ?...........
tumor marker in cancer management
• Theoriticaly tumor marker should be useful in the detection ,management
and monitoring of cancer patients ,however and unfortunately almost
available tumor markers do not posses sufficient specificity,
• Even highly specific ones suffer from poor predictive value because the
prevalence of particular cancer is relatively low among the general
population

• Also most of them have no clinical value with patient having symptoms
because elevate level are seen also in benign condition
• From that the tumor markers value are on tumor management is just
become surrounding on :

• Tumor staging .
• monitoring therapeutic response.
• predicting patient outcomes.
• detecting cancer recurence.
1-Oncofetal Antigens :
• Carcinoembryonic Antigen (CEA)
• Alpha –fetoprotein (AFP)
• CA 125.
• CA 19-9.
• CA 15-3.
• CA 549.
• Tissue poly peptide (TPA).
• Prostetic specific Antigen (PSA).
• 2- Placental Proteins:
• Human chorionic gonadotropin (hcg intact and B-hcG).
• Human Placental Lactogen (HPL).
• Placental alkaline phosphatase (Regan iso enzyme).
• 3-Enzyme and iso enzyme as tumor marker :
• Prostatic acid phosphatase (PAP).
• Creatin kinase CK –BB iso enzyme.
• Alkaline phosphatase (ALP).
• Neorone specific enolase (NSE).
• Lactate dehydrogenase (LD1) iso enzyme.
• Lysozyme (Muridinase).
• 4-Hormones:
• Eutopic Hormones (normaly secreted by the tissue):
• (HCG) trophoplastic tumor non seminatous testicular tumors.
• Epinephrine and norepinephrine-phenochromocytoma
• 5-Monoclonal immunoglobulins:
• IgG ,IgA,IgM,IgD,IgE .
• Kapa and lambda light chain.
• 6-Steroid receptor ;
• Estrogen progesteron receptors.
• Androgeen receptors.
• Cotico steroid receptor.
•
• 7-Immunophenotyping :
• Lymphoid cells.
• Myeloid cells.

• 8-Dna analysis.
• Molecular diagnosis
 Properities of ideal tumor marker
• Anideal tumor marker should posses acharacteristic that meet both
analytical and clinical requirements as follow:

• Analytical requirement:
• high analytica sensitivity.
• high anaytical specificity.
• Accuracy.
• Precission.
• Rapid turn about time.
• No complexicity .
• Low cost/one test.
• Clinical requirement:
• high sensitivity for the disease (no false negative and abl to
detect micrometastasis )
• high specificity for the disease (no false pssotive negative in
disease- fee individuals) .
• Level should reflect tumor burden.
• Level should remain relatively constant and fluctuate in
patients with stable disease
• Level should be un detectable in patients with compelete
remission.
• Shuld predict outome in patients with stable disease.
•
 Oncofetal antigen
• Oncofetal antigen are example for tumor associated antigen
• They are present in both embryonic –fetal tissue and cancer cells.
• However during fetal life can be released to the crculation in high
amounts ,but after birth are repressed and only minute amount can
present in the circulation.

• Cancerous forms of oncofetal antiges :

• Carcino embryonic antigen (CEA) :

• discovered in1965 by gold and feedman as atumor specific antigen
present in extract of tumor tissue from pt with adeno carcenoma of
gastric tract.(innitialy as tumor specific antigen)
• but high cnceteration also found in:
• benign epithelial cells of infant GiT. Pylmonary emphysema,acute
ulcerative colitis,cholicystitis,alchoholic liver cirrhosis and hepatiis.
• high level observe in smookers.
• Properities:
• Comprise alarge family of glycoproteins cell-surface
antigens.(more than 35 different members).
• 45%-57%protein this increase five fold or more
during cancer.
• Sites of productioniclude: Fetal GIT,Embryonic liver
and pancereas,colonoic carcinomas cell.
• Because of antegenic heterogeneity in CEA different
method do not always produce equivalent results.

• Clinical use:
• elevation of serum CEA can not exceed four to five
time more than the reference value in benign tumor
whyle in cancer can elevate more and more .
• The problem arise from that CEA sho lackin of
sensitivity by that 35% from patients suffering from
colorectal carcinoma doesnot show elevated level of
CEA.
Properities:

•Comprise alarge family of glycoproteins cell-surface antigens.(more than 35

different members).
•45%-57%protein this increase five fold or more during cancer.
•Sites of production include: Fetal GIT ,Embryonic liver and
pancreas ,colonoic carcinomas cell.
•Because of antigenic heterogeneity in CEA different method do not always
produce equivalent results.

Clinical use:
• elevation of serum CEA can not exceed four to five time more than the
reference value in benign tumr, whyle in cancer can elevate more and more .
•The problem arise from that CEA show lacKing of sensitivity by that 35%
from patients suffering from colorectal carcinoma does not show elevated
level of CEA.
• For that reasons CEA clinically just used as cancer monitor.
• Alpha fetoprotein;

• The first tumor associated antigen that used in cancers

management .
• It discovered in fetal circulation on 1956.
• After they found in mice with spontaneous or transplanted
hepatomas.
• Interest on them become more on 1964 when they found
elevated inpatient sera with hepatocellular carcinoma.

• Properities :
• Those group of glycoprotein antigens that similar to albumin.
• Compose of 95% protein 5%carbohydrate .
• Properities :
• Those group of glycoprotein antigens that similar to
albumin.
• Compose of 95% protein 5%carbohydrate .
• In adult ,concenteration is less than 2ng/ml

Clinical uses;
• management of hepatocellular carcinoma
• Can found elevated in ovarian, testicular, pancreatic,
gastric carcinoma.
• In adult ,concenteration is less than 2ng/ml

• Clinical uses;

• management of hepatocellular carcinoma

• Can found elevated in ovarian, testicular, pancreatic,
gastric carcinoma.
 ein
• Ca-125 :
• Is oncofetal antigen produced by ovarian epithelial cells.
• Defined by reactivity to monoclonal antibody OC- 125.
• Clinical value use to determine tumor burden and extend of disease.
• Found elevated on ovarian carcinoma and other benign disorders.

• CA19-9:
• Is an asialylated lewis blood group antigen that was initially identified in
colorectal carcinoma .found also elevated in gastric
hepatobiliary ,pancreatic and colon cancer.
• high level also observed in benign disorders: include; pancreatitis,
extrahepatic cholestasis and liver cirrhosis.
• Clinical value just only for determine disease
• recurrence.
• Ca 15-3;
• Is a high- molecular weight glycoprotein found on mammary epithelium
cells.
• Found elevate in breast, lung ,colorectal and liver cancer .also on benign
disorders of
Breast and liver.
Clinically more sensitive than CEA on detecting disease recurrence.

Ca-549 ;
Found on cell membrane and luminal surface of breast prostate and other
epithelial tissues.
Elevate level found in healthy women and men ,however it observed also in
lung prostate and breast cancer.
Are not normally observed on early stage of breast cancer so clinically used
to determine tumor burden monitoring treatment and disease
progression.
 Tissue poly peptide antigen (TPA)
• Is aprotein that compose from four subunits ( A1 , B1 ,B2, C2)
• Is synthesize during S and M phase of cell cycle so it is anindicaor fo cell
generatio time and tumor aggressiveness.
• Can increase in bacterial, viral infection and pregnancy ,as well as in lung,
colon , breast ,pancreas, rectum ,stomach prostate,bladder and uterus .
• cLinically useful in staging and prognosis
• Prostate-specific antigen: (PSA) ;
• Between 1966-1978 scientist identified proteins in seminal fluid named
Gama seminoprotein, E1,and P30 .later wang and other purified aprotein
from prostatic epithelial cells named (PSA), later …
• …..Scientist observed that the four types of proteins are closely related to
each other if they are not the same.
• Can produce also by periurethral and perirectal gland .
• In acirculation found in atrace amount binding to serine protease
inhibitor(alpha -2 macroglobulin ,alpha -1chymoantitrypsine and can bind
to alpha -1 antitrypsine .
• Binding to plasma proteins give them longer life time 2-3days.
 Placental proteins
• HCG; compose of tow subunits alpha and beta.
• Produced by syncytiotrophoblastic cells of the placenta
• Can found in low amount in healthy men and women ,however during
pregnancy increase more and ore reaching the pea after ….8-10 weeks
after conception
• Clinically used to confirm pregnancy.

• Human placental lactogen ;

• Is a lactogenic hormone that produce from the same cells producing HCG .
• Has lactogenic properities so can use as an index of placenta andfetal
well- being.
• Elevate during pregnancy very much reaching plateu at the last month
and become un detectable 24-48 postpartum.
• Can elevate in trophoblastic neoplasm but not like pregnancy.
Sex Hormones
 The male

• Pulses of GnRH (LHRH) are released from the

hypothalamus and stimulate LH and FSH release from the
pituitary.
• LH stimulates testosterone production from Leydig cells of
the testis.
• Testosterone acts systemically to produce male
secondary sexual characteristics, anabolism and the
maintenance of libido. It also acts locally within the
testis to aid spermatogenesis.
• FSH stimulates the Sertoli cells in the seminiferous
tubules to produce mature sperm .Inhibin causes feedback on
the pituitary to decrease FSH secretion.
 The female
• Pulses of GnRH, at about 2-hour intervals, stimulate release of
pituitary LH and FSH.
• LH stimulates ovarian estrogen production by the ovarian cells.
• FSH stimulates follicular development in the ovarian granulosa
cells. FSH also stimulates release of inhibin from ovarian
stromal cells, which inhibits FSH release.

• Oestrogens show a double feedback action on the pituitary ,

initially inhibiting gonadotrophin secretion (negative
feedback), but later high-level exposure results in increased
GnRH secretion and increased LH sensitivity to GnRH (positive
feedback), which leads to the mid-cycle LH surge inducing
ovulation from the leading follicle
• The follicle then differentiates into a corpus luteum,
which secretes both progesterone and estradiol
during the second half of the cycle (luteal phase).

• Oestrogen initially and then progesterone cause

uterine endometrial proliferation in preparation for
possible implantation; if implantation does not
occur, the corpus luteum regresses and
progesterone secretion and inhibin levels fall so that
the endometrium is shed (menstruation) allowing
increased GnRH and FSH secretion.
• If implantation and pregnancy follow, human
chorionic gonadotrophin (HCG) production
from the trophoblast maintains corpus luteum
function until 10-12 weeks of gestation, by
which time the placenta will be making
sufficient oestrogen and progesterone to
support itself.
• Oestrogens also induce secondary sexual
characteristics,
 prolactin secretion
• Prolactin is under tonic dopamine inhibition,
while other factors known to increase
prolactin secretion (e.g. TRH) are probably of
less importance. Prolactin stimulates milk
secretion but also reduces gonadal activity. It
decreases GnRH pulsatility at the
hypothalamic level and, to a lesser extent,
blocks the action of LH on the ovary or testis,
producing hypogonadism even when the
pituitary gonadal axis itself is intact.
 Puberty
The mechanisms initiating puberty are poorly
understood but are thought to result from
withdrawal of central inhibition of GnRH release.
Environmental and physical factors are involved in
the timing of puberty (including body fat changes,
physical exercise) as well as genetic factors.
• LH and FSH are both low in the prepubertal child. In
early puberty, FSH begins to rise first, initially in
nocturnal pulses; this is followed by a rise in LH with
a subsequent increase in testosterone/oestrogen
levels.
 Precocious puberty
• Development of secondary sexual
characteristics, or menarche in girls, at or
before the age of 9 years is pre­mature. All
cases require specialist assessment by a
pediatric endocrinologist, it may be normal
and may run in families.
 Delayed puberty
• Over 95% of children show signs of pubertal development by
age 14 years. In its absence, investigation should begin by age
15 years. Causes of hypogonadism are clearly relevant but
most cases represent constitutional delay.
• In constitutional delay, pubertal development, bone age and
stature are in parallel. A family history may confirm that other
family members experienced the same delayed development,
which is common in boys but very rare in girls.
• Basal LH/FSH levels may identify the site of a defect, and
GnRH (LHRH) tests can indicate the stage of early puberty.
• If any progression into puberty is evident clinically,
investigations are not required. When delay is great and
problems are serious (e.g. severe teasing at school), low-dose
short-term sex hormone therapy is used. Specialist
assessment is advisable.
 The menopause
The menopause, or cessation of periods, naturally
occurs about the age of 45-55 years. During the late
forties, FSH initially, and then LH concentrations
begin to rise, probably as follicle supply diminishes.
Oestrogen levels fall with grossly elevated LH and
FSH levels
• Menopause may also occur surgically, with
radiotherapy to the ovaries and with ovarian disease
(e.g. premature menopause).
 Clinical features and treatment
• Features of oestrogen deficiency are hot flushes (which occur
in most women and can be disabling), There may also be
vague symptoms of non­specific aches and pains, irritability,
depression, loss of concentration and weight gain.

• Women show a rapid loss of bone density in the 10 years

following the menopause (osteoporosis) and the
premenopausal protection from ischaemic heart disease
disappears.
• Symptomatic patients should usually be treated, but there is a
widespread use of hormone replacement therapy (HRT)
 Symptomatic improvement
• Oestrogen-deficient symptoms respond well to oestrogen
replacement, the vaguer symptoms generally, but not
always, less well.
Protection against fractures of wrist, spine and hip.

• A significant increase in the risk of breast cancer (+26%) , and

a significant increase in the risk of endometrial cancer
 Investigation of premature menopause
• Basal measurements of the gonadotrophins,
oestrogens/ and prolactin:
• Low estradiol with high gonadotrophins indicates
primary gonadal disease.
• Low levels of LH/FSH and of estradiol imply
hypothalamic-pituitary disease.
Hyperprolactinaemia can be confirmed or excluded by
direct measurement. Levels may increase with stress;
ideally, a cannula should be inserted and samples
taken through it 30 minutes later.
 Investigations
• Basal levels of FSH, LH, oestrogen and
prolactin allow initial distinction between
primary gonadal and hypothalamic-pituitary
causes .
• Ovarian biopsy may occasionally be necessary
to confirm the diagnosis of primary ovarian
failure, although elevation of LH and FSH to
menopausal levels is usually adequate.
 investigation of reproductive
endocrinology
• Demonstration of ovulation (by measurement of
luteal phase serum progesterone and/ or by serial
ovarian ultrasound in the follicular phase) or a
healthy sperm count (20-200 x 106/mL, > 60% grade I
motility and < 20% abnormal forms), provide
absolute confirmation of normal female or male
reproductive endocrinology,
but these tests are not always essential.
• Pregnancy provides complete demonstration of
normal male and female function
 Polycystic ovary syndrome
• Absence of periods or markedly irregular infrequent periods
(oligomenorrhoea) are the commonest presentation of
female gonadal disease . Polycystic ovary syndrome is the
most common cause of oligomenorrhoea and amenorrhoea
in clinical practice.
• PCOS, is characterized by multiple small cysts within the ovary
and by excess androgen production from the ovaries and to a
lesser extent from the adrenals, The ovarian 'cysts' represent
arrested follicular development
 Hirsutism and polycystic ovary
syndrome

• The extent of normal hair growth varies between

individuals, families and races,
• more extensive hair growth seen in patients
complaining of hirsutism, represent a continuum
from non visible hair to extensive cover with thick
dark hair.
 Hirsutism and polycystic ovary
syndrome
• in the female. Soft vellous hair is normally present all
over the body and this type of hair on the face and
else­where is 'normal' and is not sex-hormone
dependent.
• Hair in the beard, moustache, breast, chest, axilla,
abdominal midline, pubic and thigh areas is sex-
hormone dependent.
• Any excess in the latter regions is thus usually a
marker of increased ovarian or adrenal androgen
production, most commonly polycystic ovary
syndrome (PCOS).
• Familial hirsutism does occur, but usually involves a
distribution of hair growth which is not androgenic.
• Iatrogenic hirsutism also occurs after treatment with
androgens, or more weakly androgenic drugs such as
danazol.
• Non-androgen-dependent hair growth occurs with
drugs such as phenytoin, diazoxide, minoxidil and
ciclosporin.
• Rarer, and more serious, endocrine causes of
hirsutism and virilization include congenital adrenal
hyperplasia.
 investigation
• Serum testosterone may be elevated in PCOS . Patients with
hirsutism and
normal testosterone level frequently have low levels of
sex hormone-binding globulin (SHBG), leading to
high free androgen levels.

• 17a-Hydroxyprogesterone is elevated in classical

CAH (congenital adrenal hyperplasia)

• Gonadotrophin levels. LH hypersecretion is a

consistent feature of PCOS, but the pulsatile nature of
secretion of this hormone means that a 'classic'
increased LH/FSH ratio is not always observed on a
random sample.
• Ovarian ultrasound is a useful investigation
The typical ultrasonic features are those of a
thickened capsule, multiple cysts .
• Ultrasound may also reveal virilizing ovarian
tumours, although these are often
small.
• Serum prolactin. Mild hyperprolactinaemia is
common in PCOS
 Endocrinology

• It is the study of intracellular and

extracellular communication by
messenger molecules known as
hormones.
Thyroid Gland ( Thyroid Follicle )
Epitheliu Parafollicular (C) cell producing
m calcitonin
Follicular
of follicle cell Lymphatic
vessel

Blood
capillary

Thyroglobulin (TBG)

Basement membrane
 Thyroid Hormones Synthesis
[Link] iodide
trapping

Thyroglobulin
[Link] of
iodide to nascent
iodine
[Link] of
iodide into 3,5,3’-L-tri
tyrosine iodothyronine

3,5,3’,5’-L-tri
[Link] of iodothyronine
iodinated tyrosyl
residues of Tg
Dopamine
High plasma
cortisol
(or synthetic
glucocorticoids)
• The thyroid gland secretes T3, T4, small
amounts of inactive rT3 and minute
quantities of MIT and DIT.
• At least 85% of normal T3 production and
essentially all of rT3 production can be
accounted for by peripheral de-iodination
of T4 rather than direct secretion. (ie. non-
thyroidal tissues).
T3 is 4X more potent in biological systems than is T4.
• FT4 is the primary secretory product of the normal thyroid and
peripheral deiodination occurs in the outer ring at the 5’
position to produce T3 and in the inner ring at the 5 position to
produce rT3.
• De-iodination occurs in a number of tissues but primarily in the
liver, kidneys and muscle.
Hypothalam
us
Pituitary
Gland
Thyroid Gland

(raw
thyroid
hormone)
 Metabolism of T4
1. Outer ring or inner ring de-iodination.
2. Inactivation by de-amination.
3. 10% of T4 and T3 produced each day is
excreted in bile (partly conjugated but
mainly un-conjugated.
4. Conjugated T4/T3 is partly hydrolyzed in the
intestine
5. Un-conjugated T4/T3 reabsorbed through the
enterohepatic circulation.
6. Small amounts of unmetabolised T4/T3 are
excreted in urine.
 Disorders of Thyroid Gland

1. Hypothyroidism (Primary & Secondary)

2. Hyperthyroidism (Primary & Secondary)
3. Nonthyroidal illness
 Causes of Hypothyroidism
Primary Primary Secondary
(Goitrous) (Nongoitrous) Hypothyroidis
Hypothyroidism Hypothyroidis m
m
• Chronic • Spont. •Pituitary
lymphocytic
(Hashimoto’s) Thyroid disease
thyroiditis atrophy
• Subacute (atrophic •Hypothalami
thyroiditis myxedema)
• Postpartum c disease
thyroiditis •Radioactive
• Endemic iodine iodine
deficiency therapy
• Defects in H. •Surgical
biosynth. &
action ablation
• Drugs (lithium, •External
iodine, anti- radiation
Peripheral Resistance
thyroid) To Thyroid
 Causes of Hyperthyroidism
• Diffuse toxic •Subacute thyroiditis
hyperplasia (Grave’s •Silent lymphocytic
disease)
thyroiditis
• Toxic nodular goiter
(Plummer’s disease)
•Thyrotoxicosis factitia
• Solitary toxic •Drug-induced
adenoma thyrotoxicosis
• TSH-secreting •Struma ovarii
adenoma •Hyperfunctioning
• CG-secreting metastatic thyroid
trophoblastic tumor carcinoma
• Iodine induced
hyperthyroidism
 Clinical picture of thyroid disorders
Hypothyroidism Hyperthyroidism
• Reduced memory •Nervousness, poor conc.
• Bradycardia •Tachycardia & ht failure
• Constipation •Hyper defaecation (no
• Obesity diarrhoea)
• Hypothermia, dry cool skin •Wt loss
• Menorrhagia •Sweating , moist skin
• Galactorrhoea •Amenorrhoea, impotence,
• P.A. •Gynaecomastia
• Muscle cramps, arthralgia •Uni or bilateral exophathlmos
• Goiter (grave´s)
•Atrophic muscles
•Goiter
 THYROID FUNCTION TESTS

1- Total T4 and total T3:

Measurement of total T4 and total T3 is

misleading since if TBG is increased bound T4 & T3
will increase with false elevations of total T4 &
T3 .
 Causes of increased TBG =
Causes of false high total T4 or total T3:

1. Pregnancy.
2. Oestrogen therapy.
3. Oestrogen producing tumors.
4. Viral hepatitis.
5. Heroin addiction.
6. Hereditary TBG excess or variants of
albumin & prealbumin.
 Causes of decreased TBG = Causes of false
low total T4 or total T3

1. Androgen therapy.
2. Testosterone producing tumor.
3. Liver cirrhosis.
4. Nephrotic syndrome.
5. Malnutrition.
 2- Reverse T3 (rT3) :
N. range 10-50 ng/dL
Inactive & it differentiates between:

• Non thyroidal illness (increased rT3,

decreased T3).

• Hyperthyroidism (increased rT3, increased T3).

 3- T3 resin uptake & free thyroxin index (Obsolete):

• Free thyroxin index is used for correcting the effect of

changes in TBG index (FTI) = T4 x T3 resin uptake.
• Now, FTI is replaced by measurement of free T4 and free
T3.

4- Free T3 & free T4:

• It can discriminate better between hypo, hyper &

euthyroid states and isn't affected by changes in

TBG.
 5- TSH:

• Only s-TSH can distinguish between normal

individuals with TSH level in the level of 0.34 to
1.0 IU/ml and those with primary
hyperthyroidism showing levels below 0.34
IU/ml.

• S – TSH can detect levels as low as 0.06 IU/ml

 6 – TRH stimulation test
• Baseline TSH is measured
• TRH is given i.v.
• TSH measured at 20,30,40 min.
• TSH in euthyroid status :2 – 20 μ unit /mL

• 1ry hypo thyroid TSH >20 (exaggerated response)

2nd . Hypo pituit . TSH <2 (blunted response)

Tertiary hypo hypoth. TSH shows normal but delayed

response (1 -3h.)
 Antimocrosomal/antithyroid
peroxidase antibodies:
• Antimicrosomal antibodies are directed against
thyroid cell microsomes.
• Reactivity occurs is nearly all adults with
Hashimito’s thyroiditis + 85% Grave’s.
• Low titers in 5-10% of healthy asympotmatic
individuals.
• Thyroid peroxidase is recognized as the main and
possibly only autoantigenic component of
microsomes and has greater sensitivity and
specificity.
 Investigations of thyroid disorders :
1. Primary hypothyroidism:
Diagnosis:
• High TSH.
– 5-20/ IU/ml  sub clinical primary hypothyroidism.
& N. T4  follows after 4 – 6 months
– >20/ IU/ml  overt primary hypothyroidism.
 TSH rise may precede the decrease in T and T .
4 3
• Low total and free T4.
• Low total and free T3.
(20-30 % of 1ry hypothyroidism have N.T3.)
• Low T3 uptake and FTI.
• Positive antimicrosomal or anti-thyroglobulin antibodies
in Hashimoto's thyroiditis.
• No need to perform TRH stim. test
Other lab. Tests in 1ry hypo thyroidism:

1 – CK : High
2 – Lipids :  cholesterol & triglycerides
( lipoprotein lipase )
 LDL – cholesterol
3 – Normocytic or pernicious anemia
4 – gonadotrophins : low
5 – prolactin : High (no inhibitory effect)
 Follow up of treatment:
• Aim: Normal T4 and normal TSH (sometimes TSH is
normal only if T4 is above the upper limit of normal).
• Poor compliance is shown by a high TSH and a T4
within the normal range.
• Excess thyroxine therapy is shown by a Low TSH
and a high T4.
• The return of hormone levels to normal during the
follow up period is as follows:
– T 3 in a few days,
– T 4 in 2-4 weeks and
– TSH in 6-8 weeks.
 2. Secondary hypothyroidism:
Diagnosis:
• Low TSH.
• Low total and free T4.

• Low total and free T3.

• TRH stimulation test:

 Delayed normal response  hypothalamic lesion.

 Blunted response  pituitary lesion.

 Primary
Primary hyperthyroidism:
hyperthyroidism:
Diagnosis:
Diagnosis:
• High total and free T4.

• High total and free T3.

• High T3 uptake and FTI.

• Low TSH (use S-TSH).

• Positive antimicrosomal and antithyroglobulin disease in Grave’s
disease.
• TSIs: active grave’s.
• TSH – binding inhibitor: grave’s.
• No response to TRH stim. Test .
 N.B:

• 90% of primary hyperthyroid patients have both

increased T4 and T3'

• T3 toxicosis: high T3, normal T4, low TSH.

• T4 toxicosis: high T4, normal T3, low TSH.

• T3/T4 ratio :

>20:1 → grave’s (Ab T3 secretion)

< 20:1 → Thyroiditis ( leak of T ).

Other lab testes in 1ry hyper thyroidism
1- Lipids : low cholesterol and LDL–c
2 - GTT : Diabetic type of curve (b/c thyroxine
stimulates glycogenolysis + ↑gastric emptying +
↑intestinal glucose absorption)
3 - liver function :Abnormal AST & ALP & GGT
due to malnutrition
4 - Hypercalcemia, hypercalciuria & ↑ALP
(Osteoporsis)
5 - low sperm count
6 -  SHBG :  Testosterone & estrogens
7 – N . Or  LH / FSH .
 Follow up of treatment:
• In the first 6 months depend on T4 (or T3 in T3 toxicosis) since
TSH is still suppressed and is not reliable.
• Follow up is done every 2 months and thereafter every year
to detect hypothyroidism.
• Patients treated with thiouracil should also be followed up
by CBC (to detect agranulocytosis) and liver function tests.
• Radio active iodine or thiouracil : mostly will become
hypothyroid .
• Sub total thyroidectomy : mostly remain euthyroid.
 4. Secondary hyperthyroidism: Diagnosis:

• High total and free T4.

• High total and free T3.

• High T3 uptake and FTI.

• High TSH.
• Blunted response to TRH stimulation test.
 Thyroid function tests in Pregnancy

Pregnancy causes:
• Increased TBG leads to increased total T4 & T3. Measurement of
free T4 and free T3 is a more accurate index of thyroid status.
• In the first and second trimester there is decreased or
undetectable TSH due to the thyrotrophic effect of HCG that
causes increase in T4 & T3 that leads to decreased TSH. After 20
weeks TSH is a reliable index of thyroid state.
• TRH stim test … contraindicated during pregnancy as TRH crosses
the placenta .
 Hypothyroidism in pregnancy
• TSH to diagnose hypothyroidism
• Hypothyroid female receiving thyroxin before pregnancy :
- Free T4 & T3
- TSH Due to demand
- Monitored monthly
- pre pregnant dose resumed one month after
delivery
• Hypothyroidism in pregnancy:

•Monitored monthly to adjust dose to lowest therapeutic

amount
•Note that Thyroid stim . Antibodies in grave´s can cross
the placeuta.
 Post – partum thyroid disease :

• Thyroiditis 3 – 6 months post partum

• 1st transient thyrotoxicosis → transient
hypothyroidism → euthyroid after 1 year

• Is autoimmune (50 % show antimicrosomal Ab).

• May not need treatment.
• Occurs in 15% of women & usually of sub clinical nature.
 Non thyroidal illness (NTI) and the sick
euthyroid syndrome:
• In various illnesses affecting extrathyroidal tissues
as CHF, DM, febrile illness, renal failure, acute and
chronic liver diseases, major surgery and other
diseases affecting tissues other than the thyroid
gland, there are disturbances in the thyroid
function tests, T3, T4 & TSH. However, the patient is
clinically an euthyroid patient requiring no
treatment for the thyroid status.
 Acute phase of non-thyroidal illness:

a) Low T3 states in mild cases:

• Low total and free T3 especially relative to T4 :
indicating impaired peripheral conversion of T4 to T3.
• Normal TSH (paradoxically).
• Increased rT3 : Inner ring rather than outer ring de-
iodination is favored.
• Increased free T4: Due to impaired binding affinity to
binding proteins
• Normal total T4.
 b) Low T3-T4 states in severe cases:

• Low T3.
• Undetectable TSH in severe cases or N.
• Increased rT3.

• Low total and free T4 : Due to marked

impairment of binding to binding proteins as a
result of the presence of T4 – binding inhibitor
substance.
 2. During recovery phase:

Thyroid hormones gradually return to levels

within the reference range, but abnormal
levels may still be reported for a
considerable time. Plasma TSH may rise
transiently into the hypothyroid range, as
suppression by the stress response is
released.
 Causes of low TSH in an euthvroid patient:

• Sub clinical hyperthyroidism.

• Some drugs : Glucocorticoids , Dopamine.
• Non-thyroidal illness in severe cases.
• Pregnancy (first 20 weeks).
• During the first 6 months of treatment of
primary hyperthyroidism.
 Causes of High TSH in euthyroid patient:

• Sub clinical hypothyroidism

• Some drugs amiodarone

• Non thyroidal illness (recovery ).

 Causes of euthyroid hyperthyroxinemia
• Causes of increased TBG:
• Non-thyroidal illness (occasionally increased T4).
• Some drugs. (propranolol).
• Abnormal albumin: ↑conc. →
↑ Total T4 & T 3
↑ Free T4 & T 3 if measured by analogue
labelled H.
↑ Affinity to T4 →↑Total T4
↑ Free T4 if measured by analogue labelled H.
And normal by two step
N TSH
 Causes of euthyroid hyperthyroxinemia Cont.

• Generalized resistance to thyroid Hs:

↑TSH →↑T4 & T3 to maintain euthryoid state.

N TRH

• Auto Ab. →↑ T4 & T3 : measure TSH and free T4

by two stage.
 Causes of euthyroid hypothyroxinemia

• Causes of decreased TBG.

• Non-thyroidal illness.

• Some drugs : Salicylate:  affinity to TBG.

 Thyroglobulin
• Thyroglobulin is predominantly sequestered in the
colloid follicles .
Some TG conc. reflects the mass of differentiated
thyroid tissue, physical damage or inflamm. and the
magnitude of TSH stimulation.
TG is ↑ in :
All forms of
1. Hyperthyroidism :Grave´s, toxic nodular goitre &
thyroiditis [subacute, Hashimoto (lymphocytic)]
2. Benign thyroid nodules
3. Malignant thyroid cancer.
 Main clinical use of TG
• Post – operative monitoring of patients with
papillary, follicular & Hurthle cell carcinoma of
the thyroid.
• Differential diagnosis of hyperthyroidism due to
exogenous thyroid hormone (iatrogenic or
factitious) or endogenous causes.
• Determination in hypothyroid infants if there is
any functional thyroid tissue.
 Lab investigation of thyroid carcinoma
TG is imp . tool for the detection of thyroid remnants after thyroidectomy and radio
iodine therapy.
At a cut – off of 1UG/L,TG has
A sensitivity of 95% and 100% for detecting L.N. and skeletal metastasis
respectively with a specificity of 100% , in patients who received a total
thyroidectomy and radio active ablation for thyroid cancer .
• Cancer patients with measurable TG can have recurrent thyroid cancer in about
50% of cases.
• Cancer patient monitored by one laboratory should have their baseline re –
established if another laboratory is used because inter lab (CVs ~42%)
• Methods show hook effect .
• IRMA shows detection limit of 0.2 UG/L compared to 3UG/L previously
reported .
 Medullary carcinoma

C-cells Familial all 1-↑Calcitonin : ↑ Renal failure

calcitonin family should be In G.I.T bleeding
Other tumors
screened 2-If N. calcitonin
→ pentagastrin or drink of wisky
→↑calcitonin
3-Ca→N. or hypocalcemia
(intermittent or persistent)
4-Thyroglobulin → N
• Other causes of ↑→ active Grave
´s, subacute thyr. Adenoma,
endemic qoitre.
• Use : Progress of dis.
Response to therapy
It is most reliable
if the Patient
• is not
receiving
cortisol or
dopamine
• No pituitary
failure
Cardiac Markers
 Cardiac Markers
[Link] the loss of integrity of cardiac myocyte
membranes,
intracellular macromolecules diffuse into the
interstitium
lymphatics, and microvasculature.
2. CK, CK isoforms, troponins, and myoglobin
 Creatine Kinases
1. CK is formed by two subunits, B and M, and thus
including
isoforms CK-MB, CK-BB and CK-MM.
2. CK exists in various types of tissue.
3. CK-MB predominates in cardiac muscle.
- up to ~45% of total CK in cardiac muscle
- <1% of total CK in skeletal muscle
 Creatine Kinases
4. Serum CK-MB levels rise within 2~8 hours
after AMI.
5. CK-MB values return to normal 2~3 days
after the event.
6. Reference range in NTUH (Abbott assay)
CK 38~160 U/l
CK-MB <16 U/l
 Creatine Kinases
A ratio of CK-MB mass: CK activity  2.5
suggests MI.

CK-MB from skeletal muscle produces a

plateau pattern.
CK-MB from MI peaks at approximately 12~24
hour.
Creatine Kinases
 Troponins
1. Three subunits including troponin C, I, and T. The
complex
regulates the contraction of striated muscle.
2. TnC binds to calcium ions.
TnI binds to actin and inhibits actin-myosin
interaction.
TnT binds to tropomyosin, attaching to thin
filament.
3. Cardiac-specific isoforms
Troponins
 Troponin I
1. Cardiac Troponin I (cTnl) is a cardiac muscle protein with
a
molecular weight of 24 kilo-Daltons.
2. The human cTnl has a additional amino acid residues
on its N-terminal that are not exist on the skeletal form.
3. The half life of cTnI is estimated to be 2~4 hours.
4. Serum increase is found between 2-8 hours and returns
to
normal 7~10 days after AMI.
5. Cardiac TnI levels provide useful prognostic information.
6. Reference range in NTUH (Abbott assay)
cTnI <2 ng/ml
Troponin I

NEJM
1996;335:1342-9
 Troponin T
1. Cardiac Troponin T (cTnT) is present in fetal skeletal
muscle.
2. In healthy adult skeletal muscle cTnT is absent.
3. The gene of cTnT may be re-expressed in skeletal muscle
disease. (Clin Chem. 1999;45:2129-2135)
4. Biological half life and early serum increases of cTnT are
similar to that of cTnI.
5. Peak between 12~96 hours and return to normal 14 days
after AMI.
 Myoglobin
1. The major protein responsible for O2 supply of
striated
muscle.
2. It is released into blood rapidly (as early as 1
hour) after
damage to muscle cell.
3. Early detectable, more sensitive but non-
cardiospecific.
4. High negative predictive value.
Comparison
 Comparison

Cardiac markers in patients with CRF, n=159

(Circulation 1993;88:101-106)
 Comparison
1. CK and CK-MB may be elevated in renal and muscular
disorders.
2. Elevated cTnI level in uremic patients has been a
source
of great controversy.
3. Elevated cTnT has been found in regenerating skeletal
muscle and in patients with ESRD.
(cTnT is elevated in asymptomatic patients with CRF. Am J Clin Pathol
1996;106:118-123)
4. Myoglobin is more suitable for the detection of reinfarction.
 Utility After CABG or Vascular Surgery
1. Early ischemia or infarction after CABG is most likely to be
due to problems with the grafts.
2. Due to the surgical trauma, the usual indicators of MI
have uncertain diagnostic value.
3. It is important to establish new biochemical diagnostic
limits for perioperative MI after CABG.
4. Cardiac markers are released rapidly into blood
(washout)
in cases of successful reperfusion after surgery.
5. Elevated cTnI (Dade assay) is associated increased risk of
6-month mortality and MI. (Circulation 2002;106:2366-2371)
 Conclusion
1. Elevated serum cTnI in patients with renal
disorders,
especially in lower ranges, should be
interpreted with
caution.
2. Cardiac TnI is useful for predicting short-term
mortality in
vascular surgery patients.
3. Normal values of cardiac markers after cardiac
surgery
are still not defined.
vitamins
 Water soluble vitamins
• Vitamin B1 thiamin
• Nicotinic acid
• Vitamin B12
• Folic acid
• Vitamin C
 Vitamin B1 (thiamin)

• Cofactor in pyrovate metabolism and phosphate

shunt
• The body contains 30 times daily requirement of this
vitamin
• Deficiency: polyneuropathy (briberi) cardiac failure -
Encephalopathy
• Causes : chronic alcoholic with poor diet
 Nicotinic acid
• Precursor of NAD and NADP
essential for glycolysis and oxidative
pathway.
• Deficiency: Pellagra :erythematous
skin rash …desquamation…GIT
distubance .. diarhea and dementia.
 Folic acid
• Purine-pyramidine nucleic acid synthesis
• Deficiency is relatively common
• Macrocytic aneamia ..megaloblastic marrow
changes
• Used supplement in pregnancy to prevent
neural tube defect
 Vitamin C
• Ascorpic acid
• essential for: Normal structure and function
of collagen
• Antioxidant
• Cheap and non toxic/ therapeutic trialsare
used to confirm deficiency
• Laboratory investigation for water soluble
vitamin deficiency( with the exception of folic
acid and B12) are rarely required.
 Fat soluble vitamins
• Vitamin A
• Vitamin D
• Vitamin E
• Viamin K
 Vitamin A
• Constituent of retinal pigment
• Mild deficiency: night blindness
• Severe deficiency :degenerative eye changed
(rarely seen)
• Diet: carotenes
• Rarely measured
 Vitamin D
• Decrease exposure to sunlight ..traditional
clothing - premature baby or deficient mother
• Deficient in breast milk
• Defeciency causes :
• Rickets in children
• Osteomalicia in adults
 Vitamin E

• Tocopherol an important
antioxidant
• Defeciency causes : Hemolytic
anemia- nurological dysfunction
 Vitamin K
• Vitamin K dependant coagulation factors II,VII,IX,X
synthesized in the liver
• Oral Anti coagulant (wafarin) are vit K antagonist
• Vitamin K deficiency leading to impairment of blood
clotting and prolonged PT due to liver disease,
malabsorption syndrome
 Vitamines as drugs
• Vit E is an antioxidant, reduce risk of CHD,
protect against atherosclerosis.
• And other antioxidants
• (vit C, selenium)
• Vit A and D are toxic in excess
 Vitamin Deficiency
• Among fat soluble vitamins, vitamin
A deficiency is rare, vitamin D
leading to rickets and osteomalacia
is more common( particularly
premature infant and the elderly)
 Trace elements
• Maintaining of normal health require:
• -adequate protein
• Energy substrates
• Vitamins
• Inorganic salts and trace elements
• Body needs trace elements in very low conc
• Present in conc less than 100 part / million
• Deficiency is difficult in assessment
 Trace elements
• Chromium …. …….. deficiency causes glucose intoleranc
• Cobalt ….. ……… vit B 12 component
• Copper ………… cofactor for cytochrome oxidase
• Flurine ………… present in bone and teeth
• Iodine …….. present in thyroid hormone
• Iron …………… present in heam pigment
• Manganese ……… cofactor for several enzymes
• Selenium ……… cofactor for glutathione peroxidase
• Selicon …………. present in cartilage
• Zinc …………….. cofactor for many enzymes
• It is difficult to diagnose trace element
deficiency since plasma conc may not
reflect the body status
• Some essential nutrient are harmful
if taken in excess, (vit A, and D)
increase energy sources may
develop obesity and
steatosis,increase risk for type 2 DM