1

Understanding Liver Function Tests

in diagnosis and management of

KamalaKAMAL KISHORE

Post Graduate Scholar Dept. of PG studies in Kayachiktsa

SKAMCH&RC Bangalore

Contents

• Introduction• Functions of Liver• Liver Function Tests• Liver Disease Classification• Pre Hepatic Jaundice• Koshtashakhasrita Kamala• LFT in Koshtashakhasrita Kamala

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• Management of Koshtashakhasrita Kamala

• Hepatic Jaundice• Shakhasrita Kamala• LFT in Shakhasrita Kamala• Alcoholic Liver Disease• Management of Shakhasrita Kamala• Post hepatic jaundice• Ruddhapatha kamala• Kumbhakamala • Limitations of LFT• Discussion• Conclusion

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The liver is the second largest organ in the

body which plays central role in the

digestion & metabolism of proteins,

carbohydrates & lipids.

The disease of the liver are a major cause for

the morbidity & mortality worldwide.

One in forty deaths are due to liver diseases.

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Liver function tests (LFTs) are group of

blood tests that give information about the

state of a patient's liver.

These tests can be used to detect the

presence of liver disease, distinguish among

different types of liver disorders, gauge the

extent of known liver damage, and follow the

response to treatment.

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Most of the liver diseases cause only mild

symptoms initially, but these diseases must

be detected early

Jaundice is a clinical sign of most of the

liver diseases.

Medical Jaundice refers to any type of

Jaundice that can be managed by non-

surgical conservative measures.

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The liver disorders are seen in Ayurveda

mainly through the windows of Kamala.

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Liver is mainly responsible for the

production of bile (Bilirubin) and synthesis

of serum proteins (Albumin & Globulin).

Breakdown of RBC in spleen leads to

unconjugated bilirubin production which is

transported to liver through blood where it

is converted to conjugated bilirubin.

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Bilirubin is stored in gall bladder as Bile

and is excreted into duodenum (s.intestine)

where it is converted into urobilinogen and

is excreted in stools(as stercobilinogen)

and in urine (as urobilinogen).

A major portion of bilirubin is reabsorbed in

enterohepatic circulation.

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Test Normal ValuesTotal Bilirubin 0.3 – 1.0 mg/dl

Conjugated B. (DB) < 0.3 mg/dl

Alkaline Phosphatase 30 – 120 mg/dl

Aspartate Transaminase (AST/SGOT) 5 – 40 IU/L

Alanine Transaminase (ALT/SGPT) 5 – 35 IU/L

S. Albumin 3.5 – 5.0 g/dl

S. Globulin 2.0 – 3.5 g/dl

A/G ratio 1.2 – 1.5

Prothrombin Time 12 – 15 sec

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HEMOLYTIC JAUNDICE / PRE HEPATIC JAUNDICE

1.Inherited – Sickle cell Anaemia, Thalassemias, Glucose6phosphate deficiency.

Gilbert Syndrome, Rotor’s Syndrome

3.Acquired – B12 deficiency, Folate deficiency.

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HEPATOCELLULAR JAUNDICE / HEPATIC JAUNDICE

1.Viral Hepatitis – A, B, C, D, E

2.Parasitic Hepatitis – E. Histolytica

3.Autoimmune Hepatitis

4.Toxic Hepatitis – Drugs, Alcohol

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OBSTRUCTIVE JAUNDICE / POST HEPATIC JAUNDICE

1.Primary biliary cirrhosis, Primary sclerosing cholangitis.

2.Choledocholithiasis, parasitic infection, carcinoma, traumatic biliary strictures.

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PRE HEPATIC/HEMOLYTIC JAUNDICE

Clinical Features

Abdominal pain Only present in Crisis

Itching Absent

Past history Drugs, Blood transfusion

On Examination

Icterus - color Lemon yellow

Pallor Present Palpable gall bladder Absent

Splenomegaly Present Bleeding tendency Absent

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PRE HEPATIC/HEMOLYTIC JAUNDICE

Liver Function Tests

Unconjugated/Indirect Bilirubin

Raised

Conjugated/Direct Normal

AST or ALT NormalA:G A>G (N)Alkaline phos.& GGT

Normal

Bile Salts & Bile Pigments

Absent

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Often associated with Pandu (Anaemia)

Pitta kara ahara & vihara leading to dagdhata of pitta

asrik & mamsa.Chronic & slow onset.

Haridra Netra Twak Nakhaanana

Raktha Peeta Shakrit Mootra

Bheka Varna, Krusha & Durbala

Indriya daurbalya

Daha ,Aruchi Avipaaka,

Clinical Features

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Total Bilirubin ranges btw 4-6 mg/dl

Usually Unconjugated B. > Conjugated B.

Here liver enzymes may not be affected.

Bile Salts & Bile Pigments are absent in urine.

As Pandu is associated = Complete Blood picture required.

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Mridu Shodhana (Virechana)

Shamana Rx

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Samsarjana krama (3 – 5 days)

Pathya Sevana & continuation with Shamana aushadhi.

Snehapana for a max of 3 - 4 days with

Mahatiktaka gritha

Kalyanaka gritha

Panchagavya gritha

Indukantha gritha

Vishrama kala – 3 days (Ushanajala snana for swedana)

Virechana karma with

Trivrut lehya ( 30gms) + Draksa / Triphala kashaya

Manibhadra guda ( 30gms )

Katuki churna ( 10gms )

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HEPATIC/HEPATOCELLULR JAUNDICE

Clinical features

Icterus - color Orange yellow

Itching Transient

Past History

Contact with jaundice patient,

Drugs

On examination

Pallor AbsentPalpable gall bladder Not palpable

Splenomegaly May be present

Bleeding tendency Present

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HEPATIC/HEPATOCELLULR JAUNDICE

LiverFunctionTest

Unconjugated/Indirect Bilirubin Normal

Conjugated/Direct Increased

AST or ALT Markedly Raised

ALP & GGT Normal

A:G G>A (Chronic diseases)

Bile Salts & Bile Pigments

Present

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Haridra Netra Mutra Twak

Tila Pista Nibha VarchasJwara. Aruchi

Alpa Agni, Atopa

Hrut Gaurava

Daurbalya

Hikka,Swaasa

• Acute in onset.• Ashayapakarshaka hetu

Clinical Features

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AST & ALT is raised in hepato - cellular

conditions/infective hepatitis.

ALT is generally greater raised than AST.

Usually ALP is raised in cholestatic/malignant

infiltrations

Usually Conjugated B. > Unconjugated B.

Bile Salts & Bile Pigments are present

Serological testing needed for – Hepatitis A, B, C, D, E

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AST & ALT is raised in Alcoholic Hepatitis.

AST is greater raised than ALT.

Usually ALP is raised.

Usually Conjugated B. > Unconjugated B.

Albumin : Globulin ratio reversed

GGT is raised and is important marker of alcoholic

hepatitis.

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Kaphahara chikitsa

Mridu Shodhana (Virechana)

Shamana chikitsa

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Kaphahara chikitsa

Katu, Teekshna, Ushna, Lavana, Amla Rasa

Pradhana dravyas like

Kulattha yusha, Mulaka yusha

Lemon juice + maricha (long & black) + Ardraka

swarasa with madhu

Trikatu choorna with Madhu/Ardraka swrasa

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Once the Mala Ranjana occurs Swasthaanam Aagatam Pittam

(Bile Pigments & Bile Salts Negative)

Vayuscha Prashamam Bhavet

Nivrutha Upadrava- jwara, atopa, vistamba,

hrit gaurva, daurbhalya, alpagni, aruchi.

Go for Mridu Shodana

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Mridu ShodanaSnehana

Mrudu Abhyanga & Usna Jala Snana

Virechana Yogas like Gomutra Hareetaki

Samsarjana Krama

Pathya sevana

Continuation of the Shamana till vyadhi shamana.

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POSTHEPATIC /OBSTRUCTIVE JAUNDICE

Clinical features

Icterus - color Greenish yellow

Itching Present

Past History

Pain(stones), weight

loss(neoplasm, surgery

(strictures)

On examination

Pallor AbsentPalpable gall bladder Palpable

Splenomegaly Absent

Bleeding tendency Absent

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POSTHEPATIC /OBSTRUCTIVE JAUNDICE

LiverFunctionTest

Unconjugated/Indirect Bilirubin Normal

Conjugated/Direct Increased

AST or ALT Increased

ALP & GGT Markedly increased

A:G G>A (Chronic diseases)

Bile Salts & Bile Pigments

Present

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Common causes for Post hepatic

jaundice/obstructive jaundice are choledocholithiasis,

biliary strictures, tumors and after LFT, USG

abdomen is the usual choice of investigation.

It is managed surgically.

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Kalantarat kharibhoota

Shoona/ Shootha

Krishna peeta shakrit mootra, Rakta netra

Tandra, Moha

Aruchi, Nashtagni

Advanced liver diseases like cirrhosis,

encephalopathy etc has similar signs & symptoms as

that of Kumbhakamala like oedema, ascites, mental

confusions, coma, anorexia etc

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False positive

False negative

Rarely suggest a specific diagnosis

Assess limited number of functions

One testing = no diagnosis

Misnomer

Battery testing

Repeated testing

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Assessing most of liver diseases is easy through

LFT.

The pattern of abnormalities found in LFT

generally points to

Pre Hepatic/Hepatic/Post Hepatic jaundice.

Acute/Chronic Liver disease.

Staging of a disease .

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Despite of bahupaittika nature of the

koshtashakhasrita kamala, the amount of

pitta/bilirubin that comes to settle in shakha/skin

and conjunctiva is far minimal. Therefore it

becomes reasonable to interpret and treat the

conditions associated with haemolytic jaundice on

the lines of koshtashakhasrita kamala where

pandu/anaemia is the pre stage for it.

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Based on the tilapishtanibha varchas found in

shakhasrita Kamala, it can be interpreted more

correctly as cholestatic phase of hepatocellular

jaundice which is an umbrella term and includes

many underlying pathologies like viral, bacterial,

alcoholic, autoimmune, drugs, tumor, granuloma etc

Kumbhakamala as explained in Ayurveda is

kaalantarat (long term standing/progressed kamala)

which can be taken under Advanced Liver disease.

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Based on LFT, nidana & samprapti can be better

understood and vighatana can be planned

accordingly.

LFT are very important as a documentation part to

assess the disease progression or regression.

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LFT is the first choice of Laboratory

investigations whenever a patient approaches

with hallmark of Kamala.

Til pishta nibha varchas and LFT are the prime

considerations to diagnose types of Kamala.

Every Kayachikitsak has to rule out Surgical

jaundice through LFT & Imaging techniques

before planning treatment.

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It is not advisable to completely rely only on LFT.

Lakshanas and imaging techniques are to be

considered along with LFT for the accurate

diagnosis and management of kamala in a better

way.

“Rogamaadou parikshet tato anantaram

aushadham”

(Cha.Ch.20/20)

40THANK YOU