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Laboratory tests are ordered by the clinician for one of four reasons: 1. Screening: A small number of tests have been demonstrated to find "silent" disease in the patient who has no symptoms or signs or specific risk factors for the disease. Common examples include testing for hemochromatosis with iron studies and for hypercholesterolemia. 2. Case finding: Some tests are used to find disease in specific clinical populations at risk, even if signs or symptoms are not present. They differ from screening tests because they are not used in the general population. An example is testing the bone density of elderly women for osteoporosis. 3. Diagnosis: This is the use of tests to assist in making (or excluding) a diagnosis suggested by the symptoms and signs in patients. 4. Monitoring: Tests are often used to monitor the progress of disease, response to therapy, or concentration of medication. ALKALINE PHOSPHATASE, SERUM. Pathophysiology: This includes a number of cellular enzymes that hydrolyze phosphate esters. They are named from their optimum activity in alkaline media. High concentrations of the enzymes occur in the blood during periods of rapid growth, either physiologic or pathologic, and from cellular injury. The enzymes are normally plentiful in hepatic parenchyma, osteoblasts, intestinal mucosa, placental cells, and renal epithelium. Abnormally rapid growth or cell destruction will augment the blood concentration of these enzymes. Normal Alkaline Phosphatase: 30-120 U/L (SI Units: 0.5-2.0 nkat/L). It is high in newborns, declining until puberty and then rising every decade after 60 years of age. Increased Alkaline Phosphatase. This is usually associated with disorders of bone, liver or the biliary tract. CLINICAL OCCURRENCE: Technical Error dehydration of blood specimen; Endocrine hyperparathyroidism (osteitis fibrosa cystica), acromegaly, hyperthyroidism (effect on bone), subacute thyroiditis, last half of pregnancy; Idiopathic Paget disease, benign transient hyperphosphatasemia; Infectious liver infections (hepatitis, abscesses, parasitic infestations and infectious mononucleosis), chronic osteomyelitis; Inflammatory/Immune primary biliary cirrhosis, sarcoidosis; Mechanical/Trauma healing fractures, common bile duct

obstruction from stone or carcinoma, intrahepatic cholestasis, passive congestion of the liver; Metabolic/Toxic osteomalacia, rickets, drug reactions (intrahepatic cholestasis), chlorpropamide, ergosterol, sometimes intravenous injection of albumin, pernicious anemia, hyperphosphatasia, dehydration, rapid loss of weight; Neoplastic osteoblastic bone tumors, metastatic carcinoma in bone, myeloma, liver metastases, cholangiocarcinoma; Neurologic cerebral damage; Psychosocial abuse with skeletal trauma; Vascular myocardial, renal, and sometimes pulmonary infarction. Decreased Alkaline Phosphatase. CLINICAL OCCURRENCE: Technical Errors use of oxalate in blood collection; Endocrine hypothyroidism; Idiopathic osteoporosis; Inflammatory/Immune celiac disease; Metabolic/Toxic vitamin D toxicity, scurvy (vitamin C deficiency), milk-alkali syndrome, pernicious anemia/B12 deficiency. Pleural effusions from congestive heart failure. Semin Respir Crit Care Med. 2010 Dec;31(6):689-97 In heart failure (HF), pleural effusion results from increased interstitial fluid in the lung due to elevated pulmonary capillary pressure. Rarely, pleural effusions may occur in association with isolated right HF. HF-associated effusions are typically bilateral, but if unilateral, they are more commonly seen on the right side. The fluid typically meets the biochemical characteristics of a transudate, although in 25% of the cases it may fall into the exudative range. Testing for natriuretic peptides, such as NT-proBNP, significantly aids in diagnosing or excluding HF in patients with pleural effusion of unknown origin. The measurement of pleural fluid NT-proBNP is the best way to identify pleural effusions that meet the exudative criteria of Light but are due to HF. However, if natriuretic peptide assays are not available, calculation of the serum to pleural fluid albumin gradient represents a good substitute for making this distinction. Loop diuretics are the mainstay of therapy, although a therapeutic thoracentesis for very large effusions may occasionally be required. Pathophysiology of pleural effusion The primary cause of a pleural effusion is simply an imbalance between the fluid production and fluid removal in the pleural space. The pleural space must, under normal circumstances, have a small amount of lubricating fluid present to allow the lung surface to glide within the thorax during the respiratory cycle. Normally approximately 15 mL/day of fluid enters this potential space, primarily from the capillaries of the parietal pleura. This fluid is removed by the lymphatics in the

parietal pleura. At any one time there is about 20 mL of fluid in each hemithorax and the layer of fluid is 2 to 10 mm thick. This regulated fluid balance is disrupted when local or systemic derangements occur. When local factors are altered, the fluid is protein- and LDH-rich and is called an exudate. Local factors include leaky capillaries from inflammation due to infection, infarction, or tumour. When systemic factors are altered, producing a pleural effusion, the fluid has low protein and LDH levels and is called a transudate. This can be caused by an elevated pulmonary capillary pressure with heart failure, excess ascites with cirrhosis, or low oncotic pressure due to hypoalbuminaemia (e.g., with nephrotic syndrome). In clinical practice, transudates are often multifactorial, with renal failure plus cardiac failure plus poor nutritional status being a common trilogy. Malignant Pleural Effusion Key Points for This Section

Pleural effusion is extra fluid around the lungs. Pleural effusion may be caused by cancer, cancer treatment, or other conditions. A diagnosis of the cause of pleural effusion is important in planning treatment. Treatment may be to control symptoms of pleural effusion and improve quality of life.

Pleural effusion is extra fluid around the lungs. The pleural cavity is the space between the pleura (thin layer of tissue) that covers the outer surface of each lung and lines the inner wall of the chest cavity. Pleural tissue usually makes a small amount of fluid that helps the lungs move smoothly in the chest while a person is breathing. A pleural effusion is extra fluid in the pleural cavity. The fluid presses on the lungs and makes it hard to breathe.

Pleural effusion may be caused by cancer, cancer treatment, or other conditions. A pleural effusion may be malignant (caused by cancer) or nonmalignant (caused by a condition that is not cancer). Malignant pleural effusion is a common problem for patients who have certain cancers. Lung cancer, breast cancer, lymphoma, and leukemia cause most malignant effusions. An effusion also may be caused by cancer treatment, such as radiation therapy or chemotherapy. Some cancer patients have conditions such as congestive heart failure, pneumonia, blood clot in the lung, and poor nutrition that may lead to a pleural effusion. Pathogenesis In an autopsy series of 191 patients who had malignant tumors, 55 (28%) were found to have pleural metastases and 30 (15%) had pleural effusions. [2] In all 24 cases with lung cancer, the visceral pleura was involved with tumor, whereas in those with extrapulmonic primaries, 27 (87%) of 31 cases had visceral pleural involvement. Of the 24 cases of lung cancer, 16 (67%) had parietal pleural tumor involvement, while in the 31 cases of extrapulmonic origin, 15 (48%) had parietal pleural involvement. There were no cases where the parietal pleura alone was involved except when there was direct extension of the tumor. Neoplastic vascular invasion was seen in 43 (78%) of the 55 cases. Retrograde lymphatic spread from the mediastinum was seen in 2 cases and direct pleural involvement from a peripheral tumor in 10. In agreement with Meyer,[3] tumor emboli in the lungs and their spread to the visceral pleura is an important mechanism in pleural metastases with subsequent involvement of the parietal pleura. A series of processes is required for pleural metastasis to develop.[4,5] Several sequential events lead to pleural seeding and independent tumor growth at the focused site. The malignant cell must initially detach from the tumor and then must attach to and migrate through the blood vessel wall. Next, there must be vascular migration to the visceral pleural surface. Autocrine growth factors must be present to keep the cell viable and, lastly, angiogenesis is necessary to potentiate both local growth and spread of the tumor cells. Pleural metastases result in progressive pleural effusions from several mechanisms, one of which includes increased vascular permeability due to angiogenic factors, such as vascular endothelial growth factor (VEGF),[6] which not only causes new vessel formation but an alteration of the permeability of the mesothelium. A blockage of lymphatic drainage at any point from the stoma of the parietal pleura to the

mediastinal lymph nodes will cause pleural fluid to accumulate and is an important mechanism in pleural fluid accumulation in malignancy 1. Definisi

Normal pleura Efusi pleural adalah pengumpulan cairan dalam ruang pleura yang terletak diantara permukaan visceral dan parietal, proses penyakit primer jarang terjadi tetapi biasanya merupakan penyakit sekunder terhadap penyakit lain. Secara normal, ruang pleural mengandung sejumlah kecil cairan (5 sampai 15ml) berfungsi sebagai pelumas yang memungkinkan permukaan pleural bergerak tanpa adanya friksi (Smeltzer C Suzanne, 2002).Efusi pleural adalah penumpukan cairan di dalam ruang pleural, proses penyakit primer jarang terjadi namun biasanya terjadi sekunder akibat penyakit lain. Efusi dapat berupa cairan jernih, yang mungkin merupakan transudat, eksudat, atau dapat berupa darah atau pus (Baughman C Diane, 2000) Efusi pleura adalah istilah yang digunakan bagi penimbunan cairan dalam rongga pleura. (Price C Sylvia, 1995) Pleural Effusion At A Glance Pleural effusions describe fluid between the two layer of tissue (pleura) that cover the lung and the lining of the chest wall. A pleural effusion is due to the manifestations of another illness. In general, pleural effusions can be divided into transudates (caused by fluid leaking from blood vessels) and exudates (where fluid leaks from inflammation of the pleura and lung).

The most common causes of pleural effusion are congestive heart failure, pneumonia, malignancies and pulmonary embolism. Thoracentesis is used to draw off the pleural fluid for analysis. A thin needle is inserted between the ribs into the fluid collection. Treatment of the pleural effusion depends upon the underlying illness.