PANCREATIC FUNCTION

TEST,THYROID FUNCTION TEST &

GASTRIC FUNCTION TEST
 PANCREAS
Pancreas is a glandular organ which has a role in
both digestive system and endocrine system.
Pancreatic juice contains digestive enzymes
which assist in the digestion and absorption of
carbohydrates, lipids and proteins.
It is an endocrine organ which secretes hormones
like insulin, glucagon, somatostatin etc.,
Pancreas has alpha cells which secrete glucagon,
beta cells that secrete insulin and gamma cells
that secrete somatostatin.
 DISORDERS OF THE EXOCRINE
PANCREAS
Major exocrine pancreatic disorders are
- Acute pancreatitis
- Chronic pancreatitis
- Carcinoma of the pancreas
CAUSES OF PANCREATITIS
Acute:
- Alcohol
- Gallstones
- Infection (mumps)
- Pancreatic tumours
- Hyperlipidemia

Chronic:
- Alcohol
- Idiopathic
- Trauma
- Hypercalcemia
 ENZYMES USED IN THE DIAGNOSIS OF
PANCREATIC DISORDERS
Assays of serum amylase, lipase, trypsin,
chymotrypsin and elastase 1 are used to
investigate pancreatic diseases.
AMYLASE
It is an enzyme of the hydrolase class that
catalyzes the hydrolysis of α-1,4 glycosidic
linkages in starch and glycogen.
Salivary amylase initiates the hydrolysis of
starches while the food is present in the
mouth and esophagus.
Pancreatic amylase is synthesized by the
acinar cells of the pancreas and secreted into
the intestinal tract by the pancreatic duct
system and takes part in the digestion of
carbohydrates.
CLINICAL SIGNIFICANCE
In acute pancreatitis, a rise in serum amylase activity
occurs within 5 to 8 hours of symptom onset.
Fourfold to sixfold elevation in amylase activity is usual,
with maximal concentrations attained in 12 to 72 hours.
Activity returns to normal by third or fourth day.
The magnitude of elevation is not related to severity but
highly related to the probability of acute pancreatitis.
Urinary amylase increases in proportion to serum
amylase and remains elevated for several days in case of
acute pancreatitis.
Clinical specificity of amylase for diagnosis of acute
pancreatitis is low and it is increased in intra-abdominal
and genitourinary diseases as well.
Reference interval: 22-80 U/L
LIPASE
Lipase is a glycoprotein which hydrolyses
glycerol esters of long chain fatty acids at 1
and 3 position yielding 2 moles of fatty acids
and 2-acylglycerol.
Lipase is used to diagnose acute pancreatitis
with a clinical sensitivity and specificity of 80
to 100%.
Serum lipase activity increases within 4 to 8
hours, peaks at 24 hours, and decreases
within 7 to 14 days.
Reference range: Upto 59 U/L
TRYPSIN
Trypsin is a pancreas specific serine protease
which hydrolyses peptide bonds formed by
lysine or arginine.
The acinar cells of pancreas synthesize two
major trypsins (1 and 2) in the form of
zymogens.
Normally, free trypsinogen-1 is the major
form found in serum.
Acute pancreatitis causes elevation of TRY-1
in parallel with serum amylase levels.
Serum trypsinogen-2 increases more than
EXOCRINE FUNCTIONS
The predominant exocrine functions are the
production and secretion of pancreatic juice,
which is rich in enzymes and bicarbonate.
It is colorless and odorless
It has a pH of 8.0 to 8.3
24 hour secretion is 3000 ml.

Both invasive and non-invasive tests are

performed to measure exocrine function.
 INVASIVE TESTS
TEST PROCEDURE OUTPUT
NAME MEASURED
Lundh test Standardized meal consisting of 5% Determination of
protein, 6% fat, 15% carbohydrate, enzyme, bicarbonate,
74% non-nutrient fiber secretory volume
Secretin -After an overnight fast, basal Secretion of pancreatic
test samples of fluid are collected from juice and bicarbonate
stomach and duodenum. output are related to
-One clinical unit of secretin/kg body the functional mass of
weight is administered intravenously, pancreatic tissue.
and duodenal fluid is collected at 15
minute intervals for atleast 1 hr.

Secretin- -Patients are requested to undergo Samples are collected

ceruletide overnight fast. during 15 min intervals
test -Gastroduodenal tube is placed into and pH, bicarbonate
the duodenum under x-ray control. and enzymes are
-After basal fluid is collected for 15 measured.
min, 1U secretin/kg/h is given
intrvenously for 2 hrs.
-30 mg ceruletide/kg/h is given
NON-INVASIVE TESTS
Pancreatic insufficiency cannot be
demonstrated until 50% of the acinar cells
are destroyed.
Clinical signs of pancreatic insufficiency do
not NAME
appear until 90%
OF THE TEST
of acinar tissue is
DISORDER
destroyed.
Fecal elastase-1 Cystic fibrosis and pancreatic
insufficiency. Very low elastase-1
is seen in cystic fibrosis and low
fecal elastase (<200 μg/g) is seen
in pancreatic insufficiency.

Pancreatic elastase-1 Severe and moderate chronic

pancreatitis.
Contd…
NBT-PABA test: The tripeptide NBT-PABA,
BTP, bentiromide was orally administered to
stimulate pancreatic secretion.
- BTP is specifically hydrolyzed by
chymotrypsin in the duodenum to release
PABA.
- PABA detected in serum or urine is an
indirect measure of chymotrypsin activity.
Contd…
13C-mixed chain triglyceride test is a test of
intraluminal pancreatic lipase activity.
- Substrate is administered and breath samples
are collected over a 5 hr period and exhaled
Co2 is measured as a result of lipase activity.
Contd…
Noninvasive tests are simpler and cheaper to
perform but lack sensitivity and specificity of
invasive tests.
Biochemical tests have limited clinical
application in the diagnosis of pancreatic
diseases.
Imaging procedures like USG, Spiral CT,
MRI/MRCP can be performed.
THYROID FUNCTION TESTS
THYROID GLAND:
ANATOMY
The thyroid is a butterfly shaped gland located
in the front of the neck which consists of two
lobes connected by the isthmus.
It is 12 to 20 g in weight, highly vascular, and
soft in consistency.
Thyroid hormone synthesis begins at about 11
weeks gestation.
The secretory units of the thyroid gland are
follicles that consist of an outer layer of
epithelial cells.
 HISTOLOGY
The follicular cells rest on a basement
membrane and enclose an amorphous material
called colloid.
Colloid is mainly composed of thyroglobulin
(iodinated glycoprotein).
 PHYSIOLOGY
The thyroid gland secretes hormones such as
thyroxine (T4) and triiodothyronine (T3) .
The gland secretes small amounts of
biologically inactive reverse T3 and small
amounts of monoiodotyrosine and
diiodotyrosine, which are the precursors of
thyroid hormones.
Approximately 40% of secreted T4 is
deiodinated by peripheral tissues by
deiodinases to yield T3 and 45% is converted to
rT3.
Contd…

T3 is the biologically active form of the thyroid

hormone.
One third of T4 is converted to T3 during metabolism.
T4 is considered to be a prohormone without any
intrinsic biological activity.
> 99% of the circulating thyroid hormones are bound to
proteins( Thyroxine binding globulins, albumin,
prealbumin).
Unbound (free) hormones of T4 is 0.03% and T3 is
0.3% which is biologically active and they are not
influenced by binding protein concentration.
In non-thyroidal illness, conversion to T3 is reduced and
conversion to rT3 is enhanced.
 Synthesis and storage of thyroid hormone
Perchlorate

Pertechneta
te

Propylthiouracil
Methimazile

Following drugs inhibit thyroid hormone synthesis.

 BIOLOGICAL
Thyroid hormones FUNCTIONS
control the basal metabolic
rate.
It is required for neural development, normal
growth and sexual maturation.
It increases the heart rate and myocardial
contractility.
It stimulates protein synthesis and
carbohydrate metabolism, increased synthesis
and degradation of cholesterol and
triglycerides.
These effects are enhanced in case of
hyperthyroidism and reduced in case of
Hypothalamo- pituitary- thyroid axis
 Hypothalamus releases
TRH which acts on the
pituitary to stimulate the
release of TSH.
 TSH acts on the thyroid
gland and increases the
synthesis and release of
T3, T4.
 Increased levels of T3
and T4 inhibits the
release of TRH and TSH
due to negative feedback
mechanism.
 HYPOTHYROIDISM
CAUSES: SYMPTOMS:
 Primary hypothyroidism
 Weight gain
 Chronic lymphocytic
 Fatigue
thyroiditis (Hashimoto’s
thyroiditis)  Cold intolerance
 Radiation therapy  Hair loss
 Postoperative hypothyroidism  Constipation
 Viral & bacterial infections  Depression
 Endemic iodine deficiency
 Hoarseness of voice
 Antithyroid agents
 Dry , patchy skin
 Secondary hypothyroidism
 Elevated cholesterol
 Pituitary disease (TSH
 Puffy eyes
deficiency)
 Hypothalamic disease (TRH  Menstrual irregularities
deficiency)
HYPERTHYROIDISM
CAUSES: SYMPTOMS:
 Diffuse toxic hyperplasia  Weight loss
(Grave’s disease)  Fatigue
 Toxic multinodular goitre  Palpitations
(Plummer’s disease)  Menstrual irregularities
 Toxic solitary adenoma  Heat intolerance
 TSH secreting pituitary  Diarrhea
tumor  Tremor
 Thyroid carcinoma  Eye changes (Grave’s
 Iodine induced disease)
hyperthyroidism
 T3 toxicosis
HYPOTHYROIDISM & HYPERTHYROIDISM
Free T3 INVESTIGATIONS TO DIAGNOSE THYROID DISORDERS

Free T4
Total T3
Total T4
TSH (Thyroid stimulating hormone)
Anti- TPO (Thyroid peroxidase)
Anti- TSHR (TSH receptor)
Anti-thyroglobulin (Tg)
 SERUM
Single best or initial test TSH
of the thyroid
function.
 It is central to the negative feedback system.
It has an inverse log linear relationship with
thyroid hormone. Small changes in FT4
result in large changes in TSH.
TSH is measured by chemiluminescence
method.
Reference range:
- Non-pregnant adult: 0.34 – 4.5 mU/ml.
It is measured by SERUM T4
chemiluminescence assay.
99.97% of serum T4 is bound to thyroxine
binding globulin, albumin, transthyretin
(prealbumin).
It is the unbound form of serum T4 which is
biologically active.
 SERUM fT4
Serum fT4 is measured by chemiluminescence
assay.
fT4 is the preferred test to TSH.
Reference range: 0.58 – 1.64 ng/dl

Subclinical hypothyroidism is a condition in which thyroid hormone

levels are within reference range and TSH is mildly elevated. If TSH is
above 10 mU/L then treatment with thyroxine can be started. Subclinical
hyperthyroidism is a condition in which thyroid hormone levels are
within reference range and TSH is decreased.
T3 T3, free T3, rT3
Levels can be misleading in patients with acute
illness, cirrhosis, uremia or malnutrition.
fT3
Useful to distinguish T3 toxicosis from
subclinical thyrotoxicosis.
Reference range: 2.5 – 3.9 pg/ml
 reverse T3:
- Increased in non-thyroidal illness
- Helps to exclude central hypothyroidism
Contd…
Total T3 and T4 concentrations varies with the
concentration of thyroid hormone binding proteins .
Increase in TBG concentration are found in
Pregnancy
Newborn
Oral contraceptives
Estrogen intake
HIV infection
Decrease in TBG concentration are found in
Major illness or surgical stress
Intake of drugs like androgens, steroids, phenytoin,
salicylates.
Antibody tests done
Anti-Thyroglobulin (Tg):
- Increased in thyroid cancer patients.
Serum thyroid stimulating immunoglobulins
(TSHR-Ab)
Expensive test
Increased in Grave’s disease
Anti-thyroid peroxidase (Anti- TPO)
Organ specific and sensitive
Hashimoto’s thyroiditis
Predicts overt hypothyroidism
Reference range: < 9 IU/ml
Abnormalities of gastric function

A decrease in gastric HCl is observed in gastritis, gastric

carcinoma, pernicious anemia etc.
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