Carbohydrates

1. What is the glucose concentration in fasting whole blood?

A. Less than the concentration in plasma or serum
B. Greater than the concentration in plasma or serum
C. Equal to the concentration in plasma or serum
D. Meaningless because it is not stable

* A. When highly specific analytical methods are used, the glucose concentration in fasting whole
blood is approximately 12-15% lower than in plasma or serum. Although glucose diffuses freely between
the water phase of plasma and red blood cells, there is a higher concentration of water in plasma
(approximately 12%) than in whole blood, accounting for the increased glucose concentration in plasma.
The water content of whole blood depends on the hematocrit.

2. Of the followingblood glucose levels, which would you expect to result in glucose in the urine?
A. 60mg/dL
B. 120mg/dL
C. 150mg/dL
D. 225mg/dL

*D. Renal threshold is defined as the plasma level that must be exceeded in order for the substance to
appear in the urine. The renal threshold for glucose is 180 mg/dL. This means that the blood glucose
level must exceed 180 mg/dL in order for glucose to be excreted in the urine.

3. Which test may be performed to assess the average plasma glucose level that an
individual maintained during a previous 2- to 3-month period?
A. Plasma glucose
B. Two-hour postprandial glucose
C. Oral glucose tolerance
D. Glycated haemoglobin

*D. Glycated hemoglobin is a collective term encompassing the three glycated haemoglobin fractions—
hemoglobin A1a, hemoglobin A1b, and hemoglobin A1c. Hb A1c is the fraction of Hb A1 that is present in
the greatest concentration. Some commercially available column chromatography methods measure the
three fractions collectively. Glycated haemoglobin refers to the specific red cell hemoglobin A types to
which a glucose molecule becomes irreversibly attached. The greater the glucose concentration in the
plasma, the greater the number of hemoglobin molecules that will become glycated. Because red blood
cells have an average life span of 120 days and the glycation is irreversible, measurement of glycated
haemoglobin reflects the average plasma glucose level of an individual during the previous 2- to 3-
month period. This test is used as a monitor of diabetic control.

4. A 30-year-old pregnant woman has a gestational diabetes mellitus screening test

performed at 26 weeks of gestation. Her physician chooses to order a 50-g oral glucose load. Her serum
glucose level is 150 mg/dL at 1 hour. What should occur next?
A. This confirms diabetes mellitus; give insulin.
B. This confirms diabetes mellitus; dietary intake of carbohydrates should be lessened.
C. This is suspicious of diabetes mellitus; an oral glucose tolerance test should be performed.
D. This is an expected glucose level in a pregnant woman

* C. Increased insulin resistance is commonly seen in the late second and third trimesters of pregnancy.
Most women are able to compensate by secreting additional insulin and, thus, are able to maintain
normal blood glucose levels. In cases of gestational diabetes mellitus, women are unable to make
sufficient insulin to meet their needs. In the screening test, serum glucose is assessed at 1 hour following
the ingestion of a 50-gram glucose load (glucose challenge test). If the serum glucose is >140 mg/dL, the
next step is to perform an oral glucose tolerance test.

5. Which glucose method is considered to be the reference method?

A. Glucose oxidase
B. o-Toluidine
C. Hexokinase
D. Glucose dehydrogenase

*C. Although there are several reliable enzymatic glucose methods available, the hexokinase method is
the reference method for quantifying glucose. The reference method requires that a protein-free filtrate
be made using barium hydroxide and zinc sulfate. The clear supernatant is then used as the sample in
the hexokinase/glucose-6-phosphate dehydrogenase coupled enzyme reactions. For routine clinical use,
serum is used directly in the hexokinase method because deproteinization is too time-consuming.

6. Which of the following hormones does not promote an increase in blood glucose levels?
A. Growth hormone
B. Cortisol
C. Glucagon
D. Insulin

* D. Regulation of the blood glucose concentration depends on a number of hormones. These include
insulin, glucagon, cortisol, epinephrine, growth hormone, adrenocorticotropic hormone, and thyroxine.
Of these hormones, insulin is the only one that decreases the blood glucose level. Glucagon is produced
in the pancreas by the alpha cells. Glucagon promotes an increase in the blood glucose concentration by
its stimulatory effect on glycogenolysis in the liver. Cortisol is produced by the adrenal cortex. It
stimulates gluconeogenesis, thus increasing the blood level of glucose. Epinephrine is produced by the
adrenal medulla. It promotes glycogenolysis, thus increasing blood glucose. Growth hormone and
adrenocorticotropic hormone are produced by the anterior pituitary gland. Both hormones are
antagonistic to insulin and hence increase blood glucose. Thyroxine is produced by the thyroid gland. It
not only stimulates glycogenolysis but also increases the intestinal absorption rate of glucose.

7. As part of a routine physical, a fasting plasma glucose is performed on a 45-yearold male and the test
result is 105 mg/dL. How should this individual be classified?
A. Normal for his age
B. Impaired fasting glucose
C. Type 1 diabetes mellitus
D. Type 2 diabetes mellitus

* B. When a fasting plasma glucose test is performed and the glucose value is between 100-125 mg/dL,
the individual is considered to have impaired fasting glucose (IFG). This is less than the value associated
with diagnosis of diabetes mellitus, which is a fasting plasma glucose > 126mg/dL. IFG is considered a
risk factor and a stage between normal glucose metabolism and development of diabetes mellitus.

8. Laboratory tests are performed on a postmenopausal, 57-year-old female as part of an annual

physical examination. The patient's casual plasma glucose is 220 mg/dL, and the glycated haemoglobin
(Hb AIC) is 11%. Based on this information, how should the patient be classified?
A. Normal glucose tolerance
B. Impaired glucose tolerance
C. Gestational diabetes mellitus
D. Type 2 diabetes mellitus

* D. A casual plasma glucose should be less than 200 mg/dL. The reference range for glycated
hemoglobin (Hb Alc) is 4-6%. Because the individual is a postmenopausal, 57-year-old female, with
abnormal test results being found as part of an annual physical examination, the most likely diagnosis is
type 2 diabetes mellitus. The ADA recommends that in the absence of unequivocal hyperglycemia, the
glucose result should be confirmed by repeating the casual glucose or performing a fasting plasma
glucose on a subsequent day. The ADA does not recommend Hb A1c as a screening test for diabetes
mellitus.

Lipids and Lipoproteins

9. The turbid, or milky, appearance of serum after fat ingestion is termed postprandial lipemia, which is
caused by the presence of what substance?
A. Bilirubin
B. Cholesterol
C. Chylomicron
D. Phospholipid

* C. After fat ingestion, lipids are first degraded, then reformed, and finally incorporated by the
intestinal mucosal cells into absorbable complexes known as chylomicrons. These chylomicrons enter the
blood through the lymphatic system, where they impart a turbid appearance to serum. Such lipemic
plasma specimens frequently interfere with absorbance or cause a change in absorbance measurements,
leading to invalid results

10. What substance is the precursor to all steroid hormones?

A. Fatty acid
B. Cholesterol
C. Triglyceride
D. Phospholipid
* B. The 27-carbon, ringed structure of cholesterol is the backbone of steroid hormones. The nucleus is
called the cyclopentanoperhydrophenanthrene ring. The steroid hormones having this ring include
estrogens (18 carbons), androgens (19 carbons), glucocorticoids (21 carbons), and mineralocorticoids (21
carbons).

11. Several malabsorption problems are characterized by a condition known as steatorrhea. Steatorrhea
is caused by an abnormal accumulation of what substance in the feces?
A. Proteins
B. Lipids
C. Carbohydrates
D. Vitamins

* B. Pancreatic insufficiency, Whipple disease, cystic fibrosis, and tropical sprue are diseases
characterized by the malabsorption of lipids from the intestines. This malabsorption results in an excess
lipid accumulation in the feces that is known as steatorrhea. When steatorrhea is suspected, the amount
of lipid material present in the feces may be quantified. A 24- or 72-hour fecal specimen should be
collected, the latter being the specimen of choice. The lipids are extracted from the fecal specimen and
analysed by gravimetric or titrimetric methods.

12. The VLDL fraction primarily transports what substance?

A. Cholesterol
B. Chylomicron
C. Triglyceride
D. Phospholipid

* C. The VLDL fraction is primarily composed of triglycerides and lesser amounts of cholesterol and
phospholipids. Protein components of VLDL are mostly apolipoprotein B-100 and
apolipoprotein C. VLDL migrates electrophoretically in the prebeta region.

PROTEIN

13. Which disorder is not associated with an elevated protein level in cerebrospinal fluid?
A. Bacterial meningitis
B. Multiple sclerosis
C. Cerebral infarction
D. Hyperthyroidism

* D. CSF, an ultrafiltrate of blood plasma, is made in the choroid plexus of the ventricles of the brain.
Protein quantification is among the tests generally ordered on CSF; other tests include glucose, culture
and sensitivity, and differential cell count. The reference range for CSF protein is 15-45 mg/dL. CSF
protein may be quantified using turbidimetric (e.g., sulfosalicylic acid and benzethonium chloride) or
dyebinding methods (e.g., Coomassie brilliant blue). Elevated levels of CSF protein are found in such
disorders as bacterial, viral, and fungal meningitis; multiple sclerosis; neoplasm; disk herniation; and
cerebral infarction. Low levels of CSF protein are found in hyperthyroidism and in CSF leakage from the
central nervous system.
14. Identification of which of the following is useful in early stages of glomerular dysfunction?
A. Microalbuminuria
B. Ketonuria
C. Hematuria
D. Urinary light chains

* In renal disease, glomerular or tubular malfunction results in proteinuria. In early stages of

glomerular dysfunction, small quantities of albumin will appear in the urine. Because the concentration
is so low, urine dipstick assays are unable to detect the presence of such a small quantity of albumin;
hence the term "microalbuminuria." Annual testing of diabetic individuals for microalbuminuria is
recommended, because identification of these low levels of albumin that precede nephropathy would
allow for clinical intervention to control blood glucose levels and blood pressure. The reference interval
for urinary albumin is less than 30 mg/day. Microalbuminuria may be quantified using
immunonephelometry and enzyme immunoassay.

15. Which of the following is a low-weight protein that is found on the cell surfaces of nucleated cells?
A. C-reactive protein
B. β2-Microglobulin
C. Ceruloplasmin
D. α2-Macroglobulin

*B. β2-Microglobulin is a single polypeptide chain that is the light chain component of humanleukocyte
antigens (HLAs). It is found on the surface of nucleated cells and is notably present on lymphocytes.
Increased plasma levels of β2-Microglobulin are associated with renal failure, lymphocytosis, rheumatoid
arthritis, and systemic lupus erythematosus.

16. In a healthy individual, which protein fraction has the greatest concentration in serum?
A. Alpha1-globulin
B. Beta-globulin
C. Gamma-globulin
D. Albumin

* D. The serum proteins are divided into five principal fractions based on their electrophoretic mobility’s.
The five fractions are albumin, alpha1globulin, alpha2-globulin, beta-globulin,
and gamma-globulin. Albumin constitutes the largest individual fraction of the serum proteins. The
reference concentration of albumin in serum ranges between 3.5 and 5.0 g/dL, and the total globulin
concentration are between 2.3 and 3.5 g/dL

17. There are five immunoglobulin classes: IgG, IgA, IgM, IgD, and IgE. With which globulin fraction do
these immunoglobulins migrate electrophoretically?
A. Alphapglobulins
B. Alpha2-globulins
C. Beta1-globulins
D. Gamma-globulins

*D. All the immunoglobulins consist of heavyand light-chain polypeptides. The heavy chains
are designated as gamma γ, alpha α, mu µ, delta Δ, and epsilon ꜫ and are specific for the
immunoglobulins IgG, IgA, IgM, IgD, and IgE, respectively. The light chains are designated as kappa к
and lambda λ, with both types being found in each of the immunoglobulin classes, although the two
light chains attached to a particular set of heavy chains must be of the same type. Therefore, IgG
consists of two heavy chains of the gamma type and two light chains of either the kappa or lambda type.
The immunoglobulins IgA, IgD, and IgE have a structure similar to that of IgG in that they consist of two
light chains and two heavy chains of the respective type. IgM is a macromolecule with a pentamer type
of structure. IgM consists of five sets of two heavy-chain and two light-chain units, with the basic units
being linked to each other by peptide fragments.

18. Which of the following is an acute-phase reactant protein able to inhibit enzymatic
proteolysis and having the highest concentration of any of the plasma proteolytic inhibitors?
A. C-reactive protein
B. Haptoglobin
C. α2-Macroglobulin
D. α1-Antitrypsin

*D. α1-Antitrypsin is an acute-phase reactant protein whose concentration increases in response to

inflammation; a i-Antitrypsin inhibits the self-destruction of one's own tissue by forming inactive
complexes with proteolytic enzymes. In this way the enzymes are inhibited, and tissue destruction
through self-digestion is avoided. A1- Antitrypsin has been found to have the highest concentration in
serum of any of the plasma proteolytic inhibitors. It is an effective inhibitor of the enzymes chymotrypsin,
plasmin, thrombin, collagenase, and elastase. The primary effect of a1-antitrypsin may be seen in the
respiratory tract and the closed spaces of the body where physiological pH values are maintained, aj-
Antitrypsin is least effective in the stomach and intestines.

NPNs

19. What is the compound that comprises the majority of the nonprotein-nitrogen
fractions in serum?
A. Uric acid
B. Creatinine
C. Ammonia
D. Urea

* D. Constituents in the plasma that contain the element nitrogen are categorized as being protein- or
nonprotein-nitrogen compounds. The principal substances included among the nonprotein-nitrogen
compounds are urea, amino acids, uric acid, creatinine, creatine, and ammonia. Of these compounds,
urea is present in the plasma in the greatest concentration, comprising approximately 45% of the
nonprotein-nitrogen fraction.

20. To maintain acid-base balance, it is necessary that the blood ammonia level be kept within narrow
limits. This is accomplished primarily by which of the following?
A. Synthesis of urea from ammonia
B. Synthesis of glutamine from ammonia
C. Excretion of ammonia in the bile
D. Excretion of ammonia in the stools

* A. The catabolism of some amino acids involves a transamination reaction in which the a-amino
group of the amino acid is enzymatically removed. After its removal, the a-amino group is transferred to
an α-keto acid (α-ketoglutarate) with the formation of L-glutamate. Glutamate, which is the common
product formed by most transaminase reactions, then may undergo oxidative deamination in the liver
mitochondria with the formation of ammonia. The ammonia thus formed leaves the mitochondria as the
amino group of citrulline. Citrulline, in turn, condenses with aspartate, which contains the second amino
group needed for urea synthesis, forming argininosuccinate, which ultimately leads to the formation of
urea. Therefore, the formation of urea and its excretion in the urine provide the principal means by
which the body is able to free itself of excess ammonia.

21. Which of the following does not need to be done when collecting, handling, and using a specimen
for ammonia analysis?
A. Avoid using a hemolyzed specimen.
B. Collect blood in EDTA or heparin evacuated tubes.
C. Place specimen in a 37°C water bath immediately.
D. Advise patient not to smoke for 8 hours before blood collection.

*C. Plasma is the specimen of choice for ammonia analysis. Ethylenediaminetetra-acetic acid (EDTA) and
heparin (not the ammonium salt) are acceptable anticoagulants. Because exposure of blood to air is
contraindicated, the evacuated blood collection tube should be filled completely. The blood specimen
should be placed on ice immediately and centrifuged as soon as possible to inhibit deamination of amino
acids. Because the concentration of ammonia in red blood cells is approximately three times greater
than in plasma, the analysis should be performed on a nonhemolyzed specimen. Because of the false
increase in ammonia levels caused by smoking, patients should be instructed to refrain from smoking for
8 hours before blood collection.

22. What analyte is measured using the Jaffe reaction?

A. Urea
B. Uric acid
C. Ammonia
D. Creatinine
* D. The Jaffe reaction, which was described in 1886, is still used for creatinine analysis. The Jaffe
reaction employs the use of an alkaline picrate solution that reacts with creatinine to form a bright
orange-red complex. A drawback to this procedure is its lack of specificity for creatinine, because
noncreatinine chromogens, glucose, and proteins are also able to react with alkaline picrate.

23. An endogenous substance assayed to assess the glomerular filtration rate may
be described as being filtered by the glomeruli, not reabsorbed by the tubules, and only secreted by the
tubules when plasma levels become elevated. What is this frequently assayed substance?
A. Inulin
B. Uric acid
C. Creatinine
D. Urea

* C. Creatinine is an endogenous substance that is filtered by the glomeruli and normally is neither
reabsorbed nor secreted by the tubules. When plasma levels of creatinine rise, some secretion of
creatinine by the tubules will occur. The filtration properties of creatinine and the fact that it is a
substance normally present in blood make the creatinine clearance test the method of choice for
assessing the glomerular nitration rate.

24. What is the end product of purine catabolism in humans?

A. Urea
B. Uric acid
C. Allantoin
D. Ammonia

*B. Through a sequence of enzymatic reactions, the purine nucleosides, adenosine and guanosine,
are catabolized to the waste product uric acid. The catabolism of purines occurs primarily in the liver,
with the majority of uric acid being excreted as a urinary waste product. The remaining amount of uric
acid is excreted in the biliary, pancreatic, and gastrointestinal secretions through the gastrointestinal
tract. In the large intestine, uric acid is further degraded by bacteria and excreted in the stool.

25. In gout, what analyte deposits in joints and other body tissues?
A. Calcium
B. Creatinine
C. Urea
D. Uric acid

* D. Gout is a pathological condition that may be caused by a malfunction of purine metabolism

or a depression in the renal excretion of uric acid. Two of the major characteristics of gout are
hyperuricemia and a deposition of uric acid as monosodium urate crystals in joints, periarticular
cartilage, bone, bursae, and subcutaneous tissue. Such a deposition of urate crystals causes
inflammation of the affected area and precipitates an arthritic attack.
Liver Function

26. What enzyme catalyzes the conjugation of bilirubin?

A. Leucine aminopeptidase
B. Glucose-6-phosphate dehydrogenase
C. Uridine diphosphate glucuronyltransferase
D. Carbamoyl phosphate synthetase

* C. In order for the bilirubin-albumin complex to reach the parenchymal cells of the liver, the complex
must be transported from the sinusoids to the sinusoidal microvilli and into the parenchymal cell. The
microsomal fraction of the parenchymal cell is responsible for the conjugation of bilirubin. It is here that
bilirubin reacts with uridine diphosphate glucuronate in the presence of the enzyme uridine diphosphate
glucuronyltransferase to form bilirubin diglucuronide.

27. Which of the following functions as a transport protein for bilirubin in the blood?
A. Albumin
B. Alpha1-globulin
C. Beta-globulin
D. Gamma-globulin

* A. The cells of the reticuloendothelial system are able to phagocytize aged red blood cells and convert
the hemoglobin to the excretory product bilirubin. It is then necessary for the bilirubin to be transported
to the liver, where it is conjugated for excretion in the bile. Albumin acts as the transport vehicle for
unconjugated bilirubin in the blood, with each mole of albumin capable of binding two moles of bilirubin

28. In the condition kernicterus, the abnormal accumulation of bilirubin occurs in what tissue?
A. Brain
B. Liver
C. Kidney
D. Blood

* A. An abnormal accumulation of bilirubin in the body may be due to increased production or decreased
excretion of bilirubin.Terms frequently associated with a buildup of bilirubin include "jaundice,"
"kernicterus," and "icterus." Both jaundice and icterus are characterized by the yellow coloration of the
skin, sclera, and mucous membranes that results from increased plasma concentrations of either
conjugated or unconju gated bilirubin or both. This yellow coloration is also visible in serum and plasma
specimens in vitro. Kernicterus refers to the accumulation of bilirubin in brain tissue that occurs with
elevated levels of unconjugated bilirubin. This condition is most commonly seen in newborns with
haemolytic disease resulting from maternal-fetal Rh incompatibility. Newborns afflicted with kernicterus
will exhibit severe neural symptoms.

29. As the red blood cells disintegrate, hemoglobin is released and converted to the pigment bilirubin.
Which organ is primarily responsible for this function?
A. Spleen
B. Kidneys
C. Intestines
D. Liver

* A. The cells of the reticuloendothelial system are responsible for the removal of old red blood cells from
the peripheral circulation. As the red blood cells reach the end of their 120-day life span, the specialized
cells mainly of the spleen phagocytize the aged cells and convert the released hemoglobin into the
excretory pigment bilirubin.The bone marrow is also responsible for the destruction of a small number of
red blood cells that have not completed the maturation process. The bilirubin produced by the
reticuloendothelial cells is indirect bilirubin, which, as a protein-bound compound, is transported to the
liver for conjugation into direct bilirubin

30. Which of the following methods is not used for the quantification of serum bilirubin?
A. Bilirubinometer
B. Jendrassik and Grof
C. Zimmerman
D. Bilirubin oxidase

* C. Bilirubinometer, bilirubin oxidase, and Jendrassik-Grof are methods that have been used to quantify
serum bilirubin concentrations. The bilirubinometer is used for direct spectrophotometric assay in which
the bilirubin concentration is read directly at 454 nm. In the bilirubin oxidase method, bilirubin is oxidized
to biliverdin and the reaction is followed at 405-460 nm. The Jendrassik-Grof method utilizes a caffeine-
sodium benzoate mixture to accelerate the coupling reaction of unconjugated bilirubin with diazo
reagent to form an azo bilirubin complex. Because of a high recovery rate, the Jendrassik-Grof method is
considered to be the method of choice for bilirubin analysis

31. What condition is characterized by an elevation of total bilirubin primarily due to an increase in the
conjugated bilirubin fraction?
A. Hemolytic jaundice
B. Neonatal jaundice
C. Crigler-Najjar syndrome
D. Obstructive jaundice

* D. "Obstructive jaundice" is a term applied to conditions in which the common bile duct is obstructed
because of gallstone formation, spasm, or neoplasm. Such an obstruction blocks the flow of bile from the
gallbladder into the small intestine. This impedance of bile flow will result in a backflow of bile from the
gallbladder into the sinusoids of the liver and ultimately into the peripheral circulation. Because the liver
is not initially involved and the disorder is of posthepatic origin, the increased levels of bilirubin in the
blood are caused by the backflow of conjugated bilirubin. If the disorder is allowed to progress, the
continued backflow of bile will cause parenchymal cell destruction. Such cellular necrosis will result in a
depression of the conjugating ability of the liver, and an elevation of unconjugated bilirubin levels in the
blood will ensue.
32. Which of the following characterizes Crigler-Najjar syndrome?
A. Inabilityto transport bilirubin from the sinusoidal membrane to the microsomal region
B. Deficiency of the enzyme system required for conjugation of bilirubin
C. Inability to transport bilirubin glucuronides to the bile canaliculi
D. Severe liver cell damage accompanied by necrosis

* B. Both Crigler-Najjar syndrome and neonatal jaundice, a physiological disorder, are due to a deficiency
in the enzyme-conjugating system. With a deficiency in uridine diphosphate glucuronyltransferase, the
liver is unable to conjugate bilirubin, and both of these conditions are characterized by increased levels
of unconjugated bilirubin. Unlike Crigler-Najjar syndrome, which is a hereditary disorder, neonatal
physiological jaundice is a temporary situation that usually corrects itself within a few days after birth.

33. Which of the following disorders is not a form of hepatic jaundice?

A. Cirrhosis
B. Crigler-Najjar syndrome
C. Hepatitis
D. Neoplasm of common bile duct

* D. Abnormal conditions characterized by jaundice may be classified according to their type of liver
involvement. The three types of jaundice are prehepatic, hepatic, and posthepatic. Hepatic jaundice may
be subdivided into two groups on the basis of the type of excessive bilirubin:conjugated bilirubin or
unconjugated bilirubin.Gilbert syndrome and Dubin-Johnson syndrome are disorders in which the process
of bilirubin transport is malfunctioning. Both Crigler-Najjar syndrome and neonatal jaundice, a
physiological disorder, are due to a deficiency in theenzyme-conjugating system. Disorders such as viral
hepatitis, toxic hepatitis, and cirrhosis cause damage and destruction of liver cells so that the ability of
the liver to remove unconjugated bilirubin from the blood and to conjugate it with glucuronic acid
becomes impaired. As these disorders progress, the level of unconjugated bilirubin in the blood rises.
There is also an increase, although not as great as that of unconjugated bilirubin, in blood levels of
conjugated bilirubin. The cause is a leakage of conjugated bilirubin from damaged parenchymal cells
into the sinusoids. Neoplasm of the common bile duct is a form of posthepatic jaundice .

34. What may be the cause of neonatal physiological jaundice of the hepatic type?
A. Hemolytic episode caused by an ABO incompatibility
B. Stricture of the common bile duct
C. Hemolytic episode caused by an Rh incompatibility
D. Deficiency in the bilirubin conjugation enzyme system

* D. The enzyme uridine diphosphate glucuronyltransferase catalyzes the conjugation of bilirubin with
glucuronic acid. In newborns, especially premature infants, this liver enzyme system is not fully
developed or functional. Because of this deficiency in the enzyme system, the concentration of
unconjugated bilirubin rises in the blood, because only the conjugated form may be excreted through the
bile and urine. The increased levels of unconjugated bilirubin will cause the infant to appear jaundiced.
Generally, this condition persists for only a short period because the enzyme system usually becomes
functional within several days after birth. Neonatal physiological jaundice resulting from an enzyme
deficiency is hepatic in origin. Hemolytic jaundice resulting from either Rh or ABO incompatibility is a
prehepatic type of jaundice, whereas a stricture of the common bile duct is classified as posthepatic
jaundice.
35. Which of the following results is least consistent with a diagnosis of viral hepatitis?
A. Serum total bilirubin 7.5 mg/dL, direct bilirubin 5.5 mg/dL, indirect bilirubin 2.0 mg/dL
B. Urine urobilinogen increased
C. AST increased 10 times the upper limit of the reference range
D. ALT increased 13 times the upper limit of the reference range

* A. In viral hepatitis, hepatocyte injury and necrosis cause the release of cellular contents. ALT is more
specific for hepatocyte injury because it is significantly present in liver tissue, whereas AST is less specific
because of its significant presence not only in liver but also in many other tissues. In viral hepatitis, both
ALT and AST are significantly elevated in serum. Because liver function is compromised in viral hepatitis,
the liver will be unable to pick up urobilinogen from the enterohepatic circulation to process resulting in
increased urobilinogen excretion in the urine. Although serum total bilirubin will be elevated, the indirect
bilirubin (unconjugated) will comprise the larger fraction and the direct bilirubin (conjugated) will be the
lesser fraction. Liver function is compromised, as is the ability of the liver to pick up bilirubin and
conjugate it.