1. Hepatobiliary Disease
Investigation of
Hepatobiliary Disease

2. Aims of Investigation:
Aims of investigations in patients with suspected liver disease:
Detect hepatic abnormality
Measure the severity of liver damage
Define the structural effects on the liver
Identify the specific cause
Investigate possible complications

3. Potential complications of liver disease
Investigation of
Suspected
Liver disease
Determine
the severity &
Activity of Disease
Liver
Function Tests
Detection of
hepatic Abnormality
Biochemical
Tests
Specific etiological
Investigations
Biopsy
Investigations of the
Potential complications
of liver disease
Identification of structural
Lesions within the liver
Imaging
Coagulation
tests

4. Liver Function Tests used to assess Liver Disease
Measurement
Fluid
Assessment
Bilirubin
Plasma
Urine
Transport
Aminotransferases
Hepatocellular damage
Alkaline phophatase
Biliary obstruction
Gamma-Glutamyl transferase
Enzyme induction
Proteins (total & albumin)
Synthesis
Coagulation tests

5. Notes
Bilirubin detected in the urine identifies conjugated hyperbilirubinemia & indicates hepatobiliary disease
Alanine aminotransferase (ALT, SGPT) is more specific for liver damage than aspartate aminotraferase (AST, SGOT).

6. Biochemical Tests in Different Causes of Jaundice
Enzyme combination
Diagnostic likelihood
Aminotrasferase
Alkaline phosphatase
Hepatocellular Jaundice
Biliary Obstruction
> X 6
< X 2.5
90%
10%
< X 6
> X 2.5
80%
Other combinations
No clear separation

7. Other biochemical tests
Hyponatremia
Occur in severe liver diseases
Multifactorial in etiology
Blood urea
B. urea may be reduced due to impaired hepatic synthesis
Increased B. urea found :
Following upper GIT bleeding
In hepatorenal failure, when associated with high serum creatinin

8. Hematological Investigations
Hb concentration, WBC & platelets counts may be normal
Normochromic normocytic anemia can reflect acute upper GIT bleeding due to:
Bleeding esophageal varices
Bleeding peptic ulcer (more common among those with chronic liver disease)
Hypochromic microcytic anemia secondary to chronic blood loss from:
Peptic ulcer
Portal hypertensice gastropathy
High erythrocyte MCV (macrocytosis):
Alcohol misuse
Target cells in any jaundiced patient
Rarely, erythrocytosis occurs in hepatocellular carcinoma due to ectopic secretion of erythropoietin

9. Hematological Investigations
Leucopenia & thrombocytopenia in portal hypertension & hypersplenism
Leucocytosis in:
Cholangitis
Alcoholic hepatitis
Hepatic abscesses
Atypical lymphocytes are seen in infectious mononucleosis which might be complicated by acute hepatitis
Thrombocytosis:
Active GIT bleeding
Hepatocellular carcinoma (rare).

10. Drugs increasing plasma GGT
Barbiturates
Carbamazepine
Ethanol
Glucocorticoids
Griseofulvin
Isoniazide
Meprobamate
Phenytoin
Primidone
Rifampicin

11. Tests to determine severity & activity of liver disease
These can :
give important information on the severity of both acute & chronic liver failure
Provide prognostic information in the above clinical situations
Biochemical tests:
Liver function tests
Albumin

12. Tests to determine severity & activity of liver disease
Coagulation tests:
The liver synthesizes most coagulation factors
It requires vitamin K to activate factors II, VII, IX, X (1972)
Reduced plasma fibrinogen concentration & prolongation of prothrombin time occur in:
Severe liver damage
Prolonged biliary obstruction (associated with reduced absorption of vitamin K)
An increased prothrombin time is evidence for severe liver disease, provided that vitamin K (10 mg by slow i.v. injection) is given to exclude deficiency
Hypercoagulation can cause:
Hepatic venous thrombsis
Budd-Chiari syndrome

13. Specific Etiological Investigations
Disease
Test
Hemochromatosis
Serum ferritin
Serum iron, iron binding capacity, saturation
Polymerase Chain Reaction (PCR) for genetic abnormality
Wilson’s disease
Serum ceruloplasmin
Serum, urine, liver copper estimations
Hepatitis A infection
IgM anti-hepatitis A virus

14. Specific Etiological Investigations
Hepatitis B infections
Hepatitis B surface antigen (HBsAg)
Hepatitis B e antigen (HBeAg)
Hepatitis B viral DNA (HBV-DNA)
Anti-hepatitis B core (anti-HBc)
Anti-hepatitis B surface (anti-HBs)
Anti-hepatitis B e (anti-HBe)
Hepatitis C
Anti-hepatitis C virus antibodies (various)
PCR for hepatitis C viral DNA

15. Specific Etiological Investigations
Hepatitis D infections
Anti-hepatitis D (IgM & IgG)
Hepatitis E
Anti-hepatitis E (anti-HEV)
Autoimmune chronic active hepatitis
Serum immunoglobulins
Serum anti-nuclear factor, anti-smooth muscle and liver, kidney, micorsomal (LKM) antibodies
Primary biliary cirrhosis
Serum antimitochondrial antibodies

16. Liver Biopsy Liver biopsy can:
Confirm the severity of liver damage
Provide etiological information
Liver biopsy is relatively safe if the following conditions are met:
Cooperative patient
Prothrombin time < 4 seconds prolonged
Platelets count > 100 X109/l
Exclusion of:
bile duct obstruction
localized skin infection
advanced COPD
marked Ascites
severe anemia

17. Investigations of Complications of Hepatic Cirrhosis
Hepatic encephalopathy
Investigations for any precipitating cause
Psychometric tests
EEG
Sensory evoked potential
Portal hypertension
Upper GI endoscopy
Barium swallow & meal
Liver ultrasound
Abdominal CT scan
Wedged hepatic venous pressure
Venography of hepatic vein

18. Hepatocellular carcinoma
Complication
Investigations
Ascites
Ascitic fluid sampling (for protein concentration, WBC count, bacterial culture, cytological examination)
Liver ultrasound
Laparoscopy
Renal failure
Urine analysis
Renal ultrasound
Central venous pressure recording
Renal biopsy
Hepatocellular carcinoma
α- fetoprotein
Abdominal CT
Hepatic angiogram

19. Investigation procedures in liver disease

20. Normal liver US

21. Normal liver MRI

22. Normal liver Isotope scan

23. Gall bladder beneath the peritoneum
Liver
Gall bladder beneath the peritoneum
Laparoscopy

24. ERCP