Cholinesterase Test-Introduction, Test Result, Unit, Reference Range, Test Methods, Clinical Significance, and Keynotes


The cholinesterase test is a significant diagnostic tool in both clinical and occupational medicine. Here’s an introduction to it:

Cholinesterase Test: An Introduction

Cholinesterase is an enzyme that plays a pivotal role in nerve function in both humans and insects. It’s responsible for breaking down the neurotransmitter acetylcholine, which is vital for the transmission of nerve impulses. There are two primary types of cholinesterase in the human body: “true” or acetylcholinesterase, found mainly in nerve tissue, and pseudocholinesterase or butyrylcholinesterase, primarily found in the blood.

The cholinesterase test is commonly utilized to measure the levels of these enzymes in the blood. Its significance in medicine arises from several key areas:

  1. Organophosphate Poisoning: Organophosphate compounds, which are widely used as insecticides, inhibit cholinesterase activity. Prolonged or high exposure can lead to a buildup of acetylcholine, causing overstimulation of the nerves. The cholinesterase test can assist in diagnosing such poisonings and monitoring recovery.
  2. Liver Function: Pseudocholinesterase is produced in the liver. Therefore, abnormally low levels of this enzyme can indicate liver dysfunction or disease.
  3. Genetic Variations: Some individuals inherit a variant form of pseudocholinesterase that functions less effectively than the typical form. These individuals might be at risk for prolonged paralysis or respiratory depression when given specific anesthetic drugs, like succinylcholine.
  4. Other Uses: While less common, cholinesterase tests may also be employed in diagnosing and monitoring other conditions, including exposure to certain nerve agents or specific therapeutic drugs that inhibit cholinesterase.

Test Result, Unit, Reference Range, and Test Methods

The cholinesterase test measures the activity of the cholinesterase enzyme in the blood, predominantly focusing on pseudocholinesterase (also known as butyrylcholinesterase or plasma cholinesterase). The specifics of test results, units, reference ranges, and methods can vary based on the laboratory and the population, but here’s a general overview:

Test Result:

  • It indicates the activity of the cholinesterase enzyme in the sample. A reduced activity may suggest exposure to cholinesterase inhibitors, liver disease, or a genetic deficiency.


  • The activity of cholinesterase is typically reported in units per liter (U/L) or equivalent units based on the methodology employed.

Reference Range:

  • The reference range varies among laboratories and is based on the population they serve and the methods they use. Generally, for pseudocholinesterase in adults:
    • Male: Approximately 5,300 to 12,900 U/L
    • Female: Approximately 4,500 to 11,200 U/L
    • Remember, these are approximate values, and actual reference ranges may differ across labs.

Test Methods:

  1. Ellman Method: One of the most widely used methods, the Ellman method involves adding a substrate (acetylthiocholine or butyrylthiocholine) that reacts with cholinesterase to produce a yellow-colored product. The rate of color change, measured spectrophotometrically, is directly proportional to the enzyme activity in the sample.
  2. Titrimetric Method: This method involves titrating acetylcholine or butyrylcholine against cholinesterase activity until a certain endpoint, usually detected via an indicator or pH change.
  3. Electrometric Method: It measures the change in pH or potential due to the hydrolysis of acetylcholine or butyrylcholine by the enzyme.

Clinical Significance

The cholinesterase test holds clinical significance in various scenarios, particularly in the realms of toxicology, hepatology, and anesthesiology. Here’s a breakdown of its importance in different clinical contexts:

  1. Toxicology – Organophosphate and Carbamate Poisoning:
    • Organophosphates and carbamates are chemicals used in insecticides, herbicides, and some medications. They inhibit cholinesterase, leading to an accumulation of the neurotransmitter acetylcholine in synapses and neuromuscular junctions. This results in overstimulation of the nervous system.
    • Symptoms of poisoning can range from miosis (pinpoint pupils), salivation, muscle twitching, respiratory failure, to even death.
    • The cholinesterase test can help diagnose and monitor individuals with suspected or known exposure to these compounds. A significant reduction in cholinesterase activity is a hallmark of acute poisoning.
  2. Hepatology – Liver Function:
    • Pseudocholinesterase (also known as butyrylcholinesterase) is produced by the liver. Abnormally low levels can indicate liver dysfunction or severe liver disease.
    • In cases of acute liver damage or chronic liver disease, cholinesterase levels may be used as part of a panel of tests to assess the synthetic function of the liver.
  3. Anesthesiology – Response to Certain Anesthetics:
    • Some individuals inherit a variant form of pseudocholinesterase that functions less effectively than the usual form.
    • These individuals may experience prolonged paralysis or respiratory depression when administered specific drugs, such as the muscle relaxant succinylcholine or the anesthetic mivacurium.
    • Testing for cholinesterase activity can help identify these individuals and guide anesthetic choices.
  4. Neurology – Myasthenia Gravis:
    • While acetylcholinesterase inhibitors are a treatment for myasthenia gravis, monitoring cholinesterase levels can be helpful to adjust doses or assess compliance.
  5. Pharmacology – Monitoring Therapeutic Drugs:
    • Certain medications, like those used to treat Alzheimer’s disease (e.g., donepezil), work by inhibiting cholinesterase. Monitoring levels can be part of therapeutic drug monitoring in specific contexts.
  6. Occupational Health:
    • Individuals working in industries that use organophosphates (e.g., agriculture) might be monitored regularly using cholinesterase tests to ensure they aren’t being overexposed to these chemicals.


Here are the keynotes on the cholinesterase test:

  1. Definition: The cholinesterase test measures the activity of cholinesterase enzymes in the blood.
  2. Types of Cholinesterase:
    • Acetylcholinesterase: Primarily found in nerve tissue.
    • Pseudocholinesterase (Butyrylcholinesterase): Produced by the liver and found mainly in the blood.
  3. Clinical Significance:
    • Toxicology: Diagnoses and monitors organophosphate and carbamate poisoning.
    • Liver Health: Assesses liver function, with low levels indicating liver dysfunction.
    • Anesthesiology: Identifies patients at risk of prolonged paralysis with certain anesthetics, especially those with a genetic variant of pseudocholinesterase.
    • Occupational Health: Monitors individuals in industries using organophosphates to ensure safety from overexposure.
  4. Symptoms of Organophosphate Poisoning: Miosis, salivation, muscle twitching, and potentially, respiratory failure.
  5. Test Units: Usually reported in units per liter (U/L) or equivalent units based on methodology.
  6. Reference Range: Varies among laboratories; generally:
    • Male: Approx. 5,300 to 12,900 U/L
    • Female: Approx. 4,500 to 11,200 U/L
  7. Test Methods:
    • Ellman Method: Spectrophotometric measurement of color change.
    • Titrimetric Method: Titrating against cholinesterase activity.
    • Electrometric Method: Measures changes in pH or potential.
  8. Treatment Implications: Can guide therapeutic choices, especially in toxic exposures and anesthesia.
  9. Prevention: Essential in occupational settings to prevent overexposure to inhibiting agents.
  10. Interpretation: Results should be viewed in conjunction with clinical symptoms, exposure history, and other relevant tests.

Further Readings

  1. Books:
    • “Casarett & Doull’s Toxicology: The Basic Science of Poisons” by Curtis Klaassen: This comprehensive toxicology textbook provides insights into the effects of various toxins, including organophosphates, on the human body and the role of cholinesterase testing.
    • “Clinical Laboratory Medicine” by Kenneth D. McClatchey: This book offers details about various laboratory tests, including the cholinesterase test, and their clinical significance.
  2. Scientific Articles:
    • “Cholinesterase Testing: A Review of the Past, Present, and Future” – This article, available in the journal “Clinical Laboratory Science,” delves into the historical and contemporary relevance of cholinesterase testing.
    • “Butyrylcholinesterase: Overview, Structure, and Function” in the journal “Human Genomics”: This review article focuses on the molecular aspects of one of the cholinesterases and its significance.
  3. Government and Professional Resources:
    • Centers for Disease Control and Prevention (CDC): The CDC’s NIOSH (National Institute for Occupational Safety and Health) offers resources on organophosphate poisoning and the role of cholinesterase monitoring, especially in occupational settings.
    • World Health Organization (WHO) Guidelines: WHO has publications on pesticide poisoning, including a detailed guide on the clinical and analytical aspects of organophosphate poisoning and cholinesterase testing.
  4. Online Platforms:
    • Lab Tests Online: This patient-friendly resource explains various lab tests, including the cholinesterase test, in simple terms. It’s a project by the American Association for Clinical Chemistry.
    • Medscape: This medical website often features articles and clinical guidelines related to various tests and conditions, including the cholinesterase test.
  5. University Websites:
    • Many universities with medical schools or programs in clinical chemistry or toxicology will have online resources, lecture notes, or publications that can provide insights into the cholinesterase test.

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