1. Liver function test Ross Stringer

2. Synthetic function Albumin & clotting (INR/PT, APTT) Hepatocellular damage AST (aspartate aminotransferase) & ALT (alanine aminotransferase) Biliary dysfunction ALP (alkaline phosphatase) & GGT (gamma glutamyl transferase) Hepatic dysfunction or outflow obstruction Bilirubin (conjugated vs unconjugated)

3. System or functionMarkerSite/significanceFunction Hepatocyte integrityASTLiver, Heart, Muscle Kidney, Brain, RBC, lung, pancreas Catabolism of protein/aa’s ALTLiver CholestasisALPBone, intestine, liver, placenta Canilicular enzyme involved in bile prod. GGTHepatobiliary injuryTransfer of GG to amino acids BilirubinExcretion disorderHaemolysis end-product Liver functionAlbuminDiet/LiverHepatic synthesis Prothrombin timeVit K dependent factorsBile salts aid Vit K absorption

4. Indications for LFTs Jaundice Abdominal pain; especially RUQ Alcohol Paracetamol & other drugs Suspected viral or AI hepatitis Ascites/oedema Confusion/delirium Pre-eclampsia/obstetric hypertension Monitoring treatment Etc

5. Interpretation in context Hx: abdominal pain, wt loss, fever, diet, foreign travel, IVDU, MSM, IBD, FHx, smoking, pale stools/dark urine Ex: vitals, jaundice, ascites, cachexia, fever, hepatomegaly, masses Inx: FBC, U&E, CRP, LDH, ABG e.g. fever, jaundice, RUQ pain in traveller returning from China e.g. painless jaundice with RUQ mass e.g. fever, jaundice, raised WCC/CRP, RUQ tenderness e.g. pain following fatty meals, no fever or masses, WCC normal e.g. diabetes, raised LFTs, skin pigmentation, joint pain, fatigue

6. Type of liver injury Liver panelDiagnosis Hepatitis-like AST and ALT up to 10 ULN AST and ALT 10-40 ULN AST and ALT 40- 100 ULN AST and ALT > 100 ULN AST/ALT > 2 AST/ALT > 4 ALT>AST and high risk behavior ALT>AST and no high risk behavior AST/ALT > 1 Alcoholic hepatitis Wilson’s disease Chronic viral hepatitis B or C Haemochromatosis,Wilson’s disease, DILI NAFLD, Alpha 1 antitrypsin deficiency, Autoimmune hepatitis Cirrhosis of any type Acute viral hepatitis, autoimmune hepatitis drug induced hepatitis Ischemic liver injury Paracetamol overdose Cholestatic ALP > 5 ULN Gall stones/cholangitis, cholangiocarcinoma, drug induced liver injury, PBC, PSC

7. Hepatitic vs cholestatic Hepatitic Bilirubin 32 AST 1380 ALT 1570 ALP 230 INR 1.2 Cholestatic Bilirubin 340 AST 120 ALT 87 ALP 560 INR 1.4

8. For review at home: Abnormal LFTs is an indication for liver screen Hepatitis serology (A,B/D, C, E) Autoantibodies (ANA, SMA, AMA, LKM) Iron studies (ferritin (with CRP), TIBC, transferrin) Alpha-1 anti-trypsin Copper & caeruloplasmin Imaging of biliary tract (USS) & liver (USS, CT) Liver biopsy (if indicated)

9. MarkerAcute infectionChronic infectionPrior infection IgM anti-HAV  -- IgG anti-HAV-- No chronic phase  HB surface Ag  - Anti-HB surface--  vaccination IgM anti-HB core  -- IgG anti-HB core-  Anti-HCV  HCV-RNA  - For review at home: Overview of viral hepatitis serology

10. 68 female pruritis, lethargy, jaundice. Cachexia, no signs CLD, dark urine, pale stools Bloods Bili 78 (3-21) AST 35 (5-35) ALT 39 (5-35) ALP 156 (30-130) GGT 176 (10-55) Alb 39 (35-50) Questions 1.Abnormalities? 2.Next Inx? 3.Possible causes?

11. 68 female pruritis, lethargy, jaundice. Cachexia, no signs CLD, dark urine, pale stools Bloods Bili 78 AST 35 ALT 39 ALP 156 GGT 176 Alb 39 Questions 1.Raised bili, ALP, GGT 2.USS biliary tree 3.Gallstones, cholangiocarcinoma, pancreatic carcinoma

12. 47 female, ongoing tiredness, pruritis, low mood, altered bowel habit. Hepatomegaly, xanthelasmata Bloods Bili 13 AST 35 ALT 34 ALP 500 GGT 30 Alb 39 Questions 1.Abnormalities? 2.Sources of ALP? 3.Further Inx?

13. 47 female, ongoing tiredness, pruritis, low mood, altered bowel habit. Hepatomegaly, xanthelasmata Bloods Bili 13 AST 35 ALT 34 ALP 500 GGT 30 Alb 39 Questions 1.ALP raised 2.Biliary tree, bone, placenta 3.Liver screen 1.Esp. autoantibodies 2.Liver biopsy PBC, PSC

14. 34 male. RUQ pain, fever, sweats. Returning traveller. Tender RUQ, spiking temperatures. Bloods Bili 51 AST 46 ALT 76 ALP 10 GGT 87 Alb 42 CRP 142 Questions 1.Abnormalities? 2.Further Inx? 3.Diagnosis?

15. 34 male. RUQ pain, fever, sweats. Returning traveller. Tender RUQ, spiking temperatures. Bloods Bili 51 AST 46 ALT 76 ALP 10 GGT 87 Alb 42 CRP 142 Questions 1.Bili, transaminases 2.USS 3.Liver abscess, cholangitis

16. 32 male. Abnormal blood test at occupational health. Recent operation overseas. Non- drinker. Bloods Bili 11 AST 350 ALT 400 ALP 45 GGT 57 Alb 39 Questions 1.Pattern of LFTs? 2.Further tests? 3.Possible diagnoses?

17. 32 male. Abnormal blood test at occupational health. Recent operation overseas. Non- drinker. Bloods Bili 11 AST 350 ALT 400 ALP 45 GGT 57 Alb 39 Questions 1.ALT>AST & raised, GGT slightly raised 2.Liver screen; esp viral hep serology 3.Likely chronic viral hepatitis (B or C)