1. Int J Cur Biomed Phar Res. 2011; 1(3): 93 -97
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Original article
Comparative Study of Serum 5' Nucleotidase,Alkaline Phosphatase ,
Aminotransferases and Bilirubin in Hepatpbilrary Diseases
Dr.Anil Batta
Associate Professor, Baba Farid Univ. of Health Sciences, Faridkot, India.
ARTICLE INFO ABSTRACT
Keywords:
Cholecystitis
Differential diagnosis of liver and biliary tract depends a lot on study of various enzymes assay.
Hepatitis The development of serum enzymology has improved a lot the ability to diagnose & to monitor
Malignancy the clinical course of patients & treatment of patients with Symptomatic & asymptomatic
Alcoholc cirrhosis hepatobiliary diseases.For this a huge repository of enzyme assays is now available. The
application of serum enzymes to the diagnosis of alcoholic hepatitis was introduced a way back
in 1960s with the demonstrated usefulness of Alkaline Phosphatase assay in differential
diagnosis of jaundice. A few years after that Ladue, Wroblewski & karmen showed that higher
level of AST & ALT were characterized of some forms of hepatic disease led to an explosive
increase of interest in serum enzyme assay as a diagnostic tool. Serum enzymology has proved
to be a particular welcome addition to clinical hepatology. Of the more than 100 tests of hepatic
function that have been devised none by itself has been reliable in the distinction of
hepatobiliary diseases. The addition of selected enzyme tests to the roster of other procedures
has enhanced the precision diagnosis. Amino transferases value is often useful in monitoring
the course of acute & chronic parenchymal liver disease, though they are misleading certain
circumstances (Wrobewski & La Dua, 1985). ALT is relatively specific for hepatobiliary
disease.ALP activity may be increased in many diseases not associated with hepatic disease
like bone, pregnancy, intestine, kidney diseases. Enzyme 5' NT was selected to observe its
impact as a key enzyme for diagnosis of Hepatobiliary diseases.
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1. Introduction found in patients with ALD. Heavy drinking for as little as a fewdays
can lead to “fatty” liver, if drinking continues, in some patients this
The liver is one of the largest and most complex organs in the body.
inflammation eventually leads to alcoholic cirrhosis, in which
It stores vital energy and nutrients, manufactures proteins and
healthy liver cells are replaced by scar tissue (fibrosis), leaving the
enzymes necessary for good health, protects the body from
liver unable to perform its vital functions. This finding has lead the
disease, and breaks down (or metabolizes) and helps remove
researchers to single out an enzyme & metabolite which is specific
harmful toxins, like alcohol, from the body. Because the liver is the
& undoubtedly an early index of hepatobiliary disease [1-5].
chief organ responsible for metabolizing alcohol, it is especially
vulnerable to hepatobiliary diseases related injury. Even as few as Secondary liver cancer is a cancer that did not originate in the
three drinks at one time may have toxic effects on the liver when liver, but originated in some other part of the body and eventually
combined with certain over–the–counter medications, such as spread to the liver. It is important to realize, however, that even
those containing acetaminophen. This issue of Alcohol Alert though the tumor spread to the liver, secondary liver cancer will
examines the diagnosis and treatment of alcoholic liver disease behave according to its origin. Prostate cancer involving the liver
(ALD), a serious and potentially fatal consequence of drinking will behave like prostate cancer. Secondary liver cancer is always
alcohol. Another disorder, hepatitis C, also featured here, often is the result of primary cancer elsewhere in the body. Primary cancer
is caused by the body's cells continuously dividing and growing
* Corresponding Author : Dr.Anil Batta into a lump called a tumor. If the cancer cells that make up this
Associate Professor
Baba Farid Univ. of Health Sciences tumor escape via the bloodstream and settle in the liver, it becomes
Faridkot India secondary liver cancer [6-9].
E mail: akbattafarid@yahoo.co.in
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2. Anil Batta / Int J Cur Biomed Phar Res. 2011; 1(3): 93 -97
94
There are several primary cancer sites from which metastatic It may increase only up to 5 fold of the normal activities. Up to 10
tumors in the liver may originate, including lung, kidney, breast, fold increase is seen in carcinoma of the liver. In both cirrhosis and
stomach and colon. Even though there are many possible origins, carcinoma activity of AST is found to be higher than the ALT. Even
secondary liver cancer results from the spread of primary though the activities of both AST and ALT are elevated in the serum
colorectal cancer up to 50 percent of the time. In some cases, the of the patients with liver diseases, ALT is more liver specific
origin of secondary liver cancer cannot be found, even with enzyme as increased ALT activity in serum is hardly seen in tissues
medical testing. The reason is that the primary tumor may be too other than liver cell damage [11-14].
small to detect and is not causing any symptoms. This is Clinical Significance
occasionally referred to as unknown primary cancer. Secondary
Serum 5'NT activity is generally elevated in hepatobiliary
liver cancer has many possible origins because of the important
diseases, especially with intrahepatic obstruction, but, unlike
functions the liver performs. All of the body's blood passes
serum alkaline phosphatase, serum 5'NT activity is not increased
through the liver, leading to early metastasis Because the liver
in infancy, childhood, pregnancy, or osteoblastic disorders. It can
filters the body's blood, it is often the first site of metastatic spread.
help confirm the hepatic origin of an elevated ALP. Genetic
As a result, prognosis for secondary liver cancer does not always
deficiency of erythrocyte pyrimidine 5'NT activity is a common
mean the cancer cells have spread to other organs of the body,
cause of hereditary non-spherocytic hemolytic anemia. Acquired
making early discovery is even more important.. In malignancy the
deficiency of erythrocyte pyrimidine 5'NT activity occurs in
cancer cells detection in ascitic fluid becomes significant. So there
patients with beta-thalassemia and lead poisoning. 5'NT activity is
is parenchymal damage raising the AST/ALT. Again both 5'NT and
low in circulating monocytes, increases markedly upon their
ALP rise due to proximity of the lesion and cholestasis. Having a
differentiation to tissue macrophages, and subsequently
liver metastasis is the most important indicator of disease
diminishes during macrophage activation. Lymphocyte ecto-5'NT
progression. Monitoring the elevation of ALP levels at each
activity, a plasma membrane marker of cell maturation, is
patient's follow-up visit may be economically used as an indicator
generally low in immunodeficiency states, and undergoes
of subsequent liver metastasis. Furthermore, a change in ALP
characteristic changes in patients with certain lymphomas and
levels of greater than 120 U/L over a period of 4 to 6 months may
leukemias. In cancer patients, elevated serum 5'NT activity does
be indicative of advanced disease progression, which warrants a
not always indicate hepatobiliary involvement; in some cases,
more aggressive treatment or a change in regimen. ALP is a simple,
5'NT may be released into serum from the primary tumor or local
low cost, relatively sensitive screening tool for detecting liver
metastases [3-5].
metastasis. Future studies aiming at better defining the role of ALP
in colon cancer is significant. Here again 5'NT has an edge due to Alkaline phosphatases are present in almost all tissues of the
its relative specificity and sensitivity [10-15]. body. They are membrane bound and are zinc containing
metalloenzymes. Alkaline phosphatases are a family of
Transaminases are present in most of the tissues of the body.
isoenzymes. They hydrolyze a variety of organic phosphate esters
They catalyze the inter conversions of the amino acids and 2-
transferring phosphate groups from a donor substrate to an
oxacids by transfer of amino groups.Transaminases are specific
acceptor containing a hydroxyl group. The isoforms derived from
for the amino acid from which the amino group has to be
the tissue non-specific isoenzyme by post translational
transferred to a keto acid. 2-oxoglutarate and glutamate couple
modification include the variants of the enzyme found in the liver,
serves as one amino group acceptor and donor pair in all amino
bone, kidney and the placenta. Some malignant tumors can
transfer reactions. In both the reactions pyridoxal-5'-phosphate
produce a placental form of the enzyme called the Regan's
functions as a prosthetic group in the amino transfer reactions.
isoenzymes.
Normal serum values: AST (SGOT) - 0-41 IU/L and ALT (SGPT) - 0-
45 IU/L. In newborns value up to 120 units for AST and 90 units for Physiological bone growth elevates ALP in serum and hence in
ALT is considered normal. the sera of growing children enzyme activity is 1.5-2.5 times that
in normal adult serum. The level of ALP in the serum of women in
Clinical significance the third trimester of pregnancy is 2-3 times more than that of
Liver diseases: Determinations of activities of AST and ALT in normal level. Biliary obstruction due to any cause may elevate
serum in patients with liver diseases like viral hepatitis and other ALP level by increasing its synthesis from the hepatocytes
forms of liver diseases with necrosis, give high valueseven before adjacent to the biliary canaliculi. This newly synthesized ALP
the appearance of clinical signs and symptoms like jaundice. enters the circulation and elevates the enzyme level in the serum.
Activity levels of 20 to 50 fold higher than normal are frequently Elevation of ALP in the serum is more with extra hepatic
seen in liver cells damage but it may reach as high as 100 times in obstruction by stones or by carcinoma head of pancreas than in
severe damage to cells. Highest serum activities are seen between intrahepatic obstruction. The enzyme level may return to normal
7th and 12th days and return to normal levels by the 3rd to 5th on removal of the obstruction. Liver diseases affecting
week. In sevre tissue damage ALTactivity is higher than AST and parenchymal cells like infectious hepatitis show only moderate
the ALT:AST ratio becomes ≥ 1 (normally <1). Some increase in elevation or normal serum ALP levels. Bone diseases with
the activities of ALT and AST are seen in extra hepatic cholestasis. increased osteoblastic activity shows increased ALP level in the
In cirrhosis the level of activities vary with the severity of the serum. Serum ALP activity may be increased in many diseases not
disease.

3. Anil Batta / Int J Cur Biomed Phar Res. 2011; 1(3): 93 -97
95
associated with liver like bone diseases, pregnancy, normal growth years. Out of these 40 served as control taking good diet, without
and occasionally the presence of malignancy not involving either HO smoking & drinking & taking healthy diet. While 60 patients of
bone or liver. For this reason the tissue, the organ of tissues of origin different diseases hepatobiliary diseases on the bases of clinical
must be identified. Serum hepatic ALP is usually increased in the findings were selected as follows:
bile duct obstruction but this increased enzyme reflects more of
1) Group 1) 21 patients suffering from Cholecystitis with
enzyme synthesis rather than decreased biliary excretions or
cholelithiasis.
leakage from damaged cells. On the other hand 5'Nucleotidase 2) Group 2) 19 patents of hepatic malignancy
(5'NT) is increased in hepatobiliary diseases doesn't usually rise in 3) Group 3) 33 Infective Hepatitis cases
bone diseases. 4) Group4) 27 cases suffered from alcoholic liver disease (ALD).
The serum activity of 5'NT is increased in cholestasis & its major Jaundice : 27 cases showed as a clinical finding.
clinical value is that it may be of help in identifying the source of 2.1 Collection of Serum
elevated serum ALP activity.
About 20 ml. of blood was collected by venepuncture using all
But we are concerned about a marker which is significant in all aseptic method & allowed to clot at room temperature. It was
hepatobiliary diseases. In this work we explored the significance of centrifuged at 3000 rpm for 10 minutes to separate serum.
5'NT,ALP,AST,ALT and serum bilirubin. 5'NT is the enzyme which is Following methods were adopted:
increased in hepatobiliary diseases. It is phosphatase which is
involved in release of inorganic phosphate only from the nucleoside Estimation of following enzymes was done by following
5' –phosphate, e.g. it acts on adenosine 5'-monophosphate (AMP) to colorimetric methods:
form adenosine and release inorganic phosphate. It is ubiquitously 1. Serum 5'—Nucleotidase—Method of Campbell 1962.
present in all the tissues and is localized in the plasma membrane of 2. Serum Alkaline Phosphatase –Method of kind & King 1954
the cells in which it is present. Serum 5'NT activity is generally using aminoantipyrine.
elevated in hepatobiliary diseases, especially with intrahepatic 3. Serum ALT | AST by method of Reitman & Frankel, 1957.
obstruction. But, unlike serum alkaline phosphatase, serum 5'NT 4. Serum bilirubin by method of Malloy & Evelyn, 1937.
activity is not increased in infancy, childhood, pregnancy, or However all the results were counterchecked so as to remove
osteoblastic disorders. It can help confirm the hepatic origin of an problem of any discrepancy. These were done by fully automated
elevated ALP [15-20]. device.
3. Results
2. Materials & Methods
Are expressed (Table-1& Figures) as Mean ±SEM. Stastical
Keeping in mind the Helsinki guidelines all patients were asked significance was determined by students'' test for unpaired data.
for permission. All patients attending the OPD & Indoor of Rajindra The value significance was evaluated with 'p' values. The differences
Hospital, Patiala were selected. Study was conducted on 100 were considered significant at p<0.001.
patients of different hepatobiliary disease .Age group was 20 to 60
Table 1. Statistical analysis of serum levels in study Group
Group and Number of Total Bilirubin AST IU/L ALT IU/L ALP KAU/L 5'NT IU/L Total Albumin
Diagnosis patients mg% Mean Mean Mean Mean Protein G% G%
studied Mean (Range) Range Range Range Range Mean Range Mean Range
I. Cholecystitis with Cholecystitis 2.27±4.43 52.9±5.91 50.45±12.96 276±34.88 120.9±19.1 6.34±1.01 2.3±0.09
cholelithiasis 21 (0.4--19) (22-48) (33-64) (147-287) (46-187) (6.2-6.7) (1.8-2.5)
2.hepatic Hepatic 5.95±6.55 66.88±7.16 69.34±10.98 287±26.18 52.28±13.45 5.50±0.19 1.23±0.65
malignancy malignancy (0.6—22) (41-97) (45-76) (159-323) (28-121) (5-6.01) (1.32-0.98)
19
3.Infective Viral hepatitis 8.46±4.5 53.87±13.20 65.87±9.87 76.90±12.98 59.34±2.98 7.23±1.98 1.87±0.43
hepatitis 33 (4-16) (43-88) (49-88) (65-87) (50-76) (7.8-5.6) (1.76-2.09)
4.Alcoholic Alcohol (2.54±1.3) 57.53±7.32 51.12±7.8 198±69.5 50.28±13.76 6.34±2.56 0.98±0.02
liver disease liver disease (42-65) (38-52) (198-298) (34-98) (5.9-6.8) (0.87-0.99)
27
Control 40 19.98±2.87 20.2±3.5 130±25.12 12.9±2..12 7.67±0.17 2.34±0.87
(20-24) 16-28 (121-145) (18-20) (7.32) (0.17-0.21)
Hepatobiliary 100 4.66±5.77 62.66±25.87 67.45±8.8 (198±287) 49.09±87.54 6.12±2.5 1.12
diseases (0.6-22) (46-165) (59-121) (43-97) (6.32) (1.87)

4. Anil Batta / Int J Cur Biomed Phar Res. 2011; 1(3): 93 -97
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Figure 1. more helpful in ALD. Raised bilirubin is insignificant when
compared with Serum ALT| AST & 5'NT in cirrhosis or chronic ALD.
Contrary to other workers we found 5'NT is markedly significant
than ALP. There is markedly low level of serum proteins as they are
produced by liver as it is major synthesizer of proteins. Because of
this there is low blood volume which causes hypotension due to
hemodynamic disturbance. In Cholecystitis with cholelithiasis real
time Ultrasound allowed distinction between extra hepatic causes
with dilated bile ducts within the liver from intrahepatic cause.
ALT|AST were markedly raised but insignificant.
ALP is significantly increased than 5'NT as bile salts is increased
in hepatocytes & solubilize the plasma membrane.5'NT is
significantly raised in extra & intra hepatic cholestasis. Hepatic
malignancy is fourth big cause of liver cancer & is third for mortality
(Parkin 2005). In India, hepatitis B is major risk factor in third world
countries. More than 80% are due to background of cirrhosis which
causes angiogenesis & is characteristic sinusoidal capiliarization.
Figure 2. Increased expression of enzymes in endothelial cells along with
deposition of extra cellular matrix & micro vessel formation there
Liver is the most common site of distant metastasis due to unique
vascular architecture liver allows metastasis as it is a storehouse of
nutrients, oxygen through various mechanism like angiogenesis.
According to Barcelona clinical liver classification carcinomas are
grade 'c',tumour, stage is advanced, there are large multiple nodules
with vascular invasion & extra hepatic secondaries. Total bilirubin
& aminotransferases levels were not significantly raised. '5' NT
levels were raised significantly due to angiogenesis, total proteins &
serum albumin level were significantly decreased.
5. Conclusion
By all practical purposes liver biopsy is the best test to study
4. Discussion chronic liver disease as part of management. This explains severity
of liver damage & fibrosis (Bravo A Aet al, 2001).but this is hurting,
Patients were scanned of all 4 groups. There is an intra
complicated, costly, invasive & full of error.Mortality rate among
comparison between patients with Alcoholic Liver Disease & in
them is 0.3%.
cholecystitis.
As a result of those problems & reluctances of patients to go for it
The patients with ALD & cirrhosis (Group 4) compared with
biochemical biomarkers carry an upper hand to precisely predict
patients of hepatic malignancy (Group 2) show loss of protein
the severity of liver disease (Carl.A lehmann, 2005) So this warrants
causing significant loss of weight. This is explained due to reduced
a cautious approach in interpreting results of the tests. But if taken
adipose tissue .In viral Hepatitis (Group 3) hyperbilirubinemia is
together the data provides reason that 5'NT is so widely raised but it
common symptom like in many other groups of patients but it
is not confined to be a marker of ethanol consumption, it's very
separated hepatic malignancy (Group 3) from other Groups.
much useful in deciding the cause of raised ALP in liver either from
Severity of rise in ALT is more significant than serum AST in this
bone/liver, very much useful in differentiation of mechanical biliary
group. 5' NT & ALP were also somewhat significant (p<0.01).Ratio
obstruction & intra hepatic cholestasis represents one of the classic
of AST/ALT was lower than in normal individuals. In acute hepatitis
diagnostic challenge in clinical medicine. Most of clinicians consider
AST & ALT were more significant than 5'NT.It was also observed that
5' NT as a significant indicator in obstructive choleststasis
it was more significant in hepatitis B & hepatitis C as compared to
conditions: However the rise in serum 5'NT increases several days
biliary canaliculi enzymes. Toxicity of alcohol is common in Indians
after obstruction of biliary ductile system & may lag behind the
3.5% of global burden is due to this (Racial & Ethnic 2002) Ethanol
elevations in serum ALP.
induced endotoxaemia & acetaldehyde which is produced by
oxidation of ethanol is more often a cause of liver damage. This is So ultimately based on our study we conclude 5'NT is a
due to free radical or sometimes by not. Conjugated levels of significant, non-invasive biochemical tool in the differential
bilirubin are raised much more in ALD. Deficiency of pyidoxal diagnosis of all hepatobiliary diseases when it is juxtaposed with
phosphate is common in ALD..Ratio of AST/ALT is more in heavy ALP, AST, ALT and bilirubin level.
drinkers. It is a good marker of ALD. Level of 5'NT with ALP was

5. Anil Batta / Int J Cur Biomed Phar Res. 2011; 1(3): 93 -97
97
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