Investigations in Liver Disease

Question 1

What blood tests are done in liver disease?

Answer 1

LFTs
Liver Screen
Haemolysis Screen if indicated

Question 2

What imaging is done?

Answer 2

US/Fibroscan
CT
MRI/MRCP

Question 3

Apart from bloods and imaging what other Ix are done?

Answer 3

Liver biopsy

Endoscopy - diagnostic, ERCP

Question 4

ALT

Answer 4

Alanine Aminotransferase

Liver specific

Question 5

What does AST stand for?

Answer 5

Aspartate Aminotransferase

Question 6

What does ALP stand for?

Answer 6

Alkaline Phosphatase

Question 7

What does GGT stand for?

Answer 7

Gamma glutamyl transpeptidase

Question 8

What is AST?

Answer 8

Mitochondrial
Heart/muscle/kidney
Raised in hepatitis

Question 9

What is ALP?

Answer 9

Bone/placenta
Bine canalicular and sinusoidal membranes
Cholestasis = intra/extrahepatic

Question 10

What is GGT?

Answer 10

Hepatocellular conditions
cholestasis
Alcohol excess

Question 11

What other things are done in LFTs apart from enzymes

Answer 11

Bilirubin
PT - prothrombin time
Albumin

Question 12

When are liver enzymes raised?

Answer 12

Inflammation

Hepatitis

Question 13

When are other liver function measures raised?

Answer 13

Chronic liver disease - synthetic problem

Question 14

What viral screens are done?

Answer 14

HbsAg
HCV Ab
IgM HAV
IgM HEV

Question 15

What immunoglobulins are looked for?

Answer 15

IgA = alcoholic liver disease
IgM = PBC
IgG = autoimmune hepatitis

(cirrhosis may have elevated all 3)

Question 16

Auto-antibodies

Answer 16

PBC = AMA subtype M2
AIH = ANA, SMA, SLA
PSC = ANCA

Question 17

Metabolic liver disease blood tests

Answer 17

NAFLD = high lipids, high fasting sugar
Haemochromatosis = high ferritin, HFE genotype
Wilsons = caeruloplasmin in <40 yrs
A1AT = co-factor in adults

Question 18

What is the blood test pattern of a cholestatic condition?

Answer 18

High ALP

With or without high bilirubin (high if more severe)

Question 19

What is the blood test pattern of a hepatic condition?

Answer 19

High enzymes

High bilirubin if more serious

Question 20

What is the blood test pattern of a synthetic condition?

Answer 20

Low albumin
Long PT
Low platelets

Question 21

What is the blood test pattern of a mixed condition?

Answer 21

High bilirubin
High enzymes
High ALP

Question 22

Causes of a synthetic condition

Answer 22

Cirrhosis

Question 23

Causes of a hepatic condition

Answer 23

NAFLD
Alcohol liver disease
Drugs
Autoimmune hepatitis
Viral

Question 24

Causes of a cholestatic condition

Answer 24

Common bile duct Stones
Drugs - microscopic biliary tree damage
PBC/PSC

Question 25

Causes of mixed conditions

Answer 25

Alcoholic liver disease Drugs NAFLD

Question 26

What is the first imaging step?

Answer 26

Always ultrasound

Question 27

Signs of cirrhosis on US

Answer 27

``` Nodular Ascites Enlarged spleen Dilated portal vein Reverse portal vein flow ```

Question 28

Signs of biliary/duct dilatation on US

Answer 28

Pancreatic tract stones or cancer | Common bile duct stones

Question 29

Space occupying lesions in liver US use

Answer 29

Primary HCC or metastases

Question 30

What further imaging would you do after US?

Answer 30

CT triple phase - nature of lesion | MRI/MRCP

Question 31

What is MRCP good for?

Answer 31

To look at biliary tree better

Question 32

Percutaneous liver biopsy

Answer 32

Diagnostic + staging | Bleeding risk

Question 33

Transjugular liver biopsy

Answer 33

Reduced risk of bleeding Less pain Smaller size of specimen Hepatic vein pressure readings

Question 34

When is a biopsy required?

Answer 34

Confirm scarring | Detect cancer

Question 35

When can transjugular liver biopsy be better?

Answer 35

Cirrhosis - impaired clotting not good with risk of bleeding & ascites

Question 36

Fibroscan

Answer 36

- measures liver stiffness - elevated score = scarring - non invasive so less need for biopsies - diagnosis and monitoring

Question 37

Use of endoscopy

Answer 37

``` Varices screening - detect bleeding risk - grade 1-4 Treatment of varices - oesophageal ligation or banding -injection of glue for gastric varices Surveillance of varies ```

Question 38

ERCP

Answer 38

Endoscopic Retrograde Cholangio Pancreaticography - fluoroscopic guidance - diagnostic and therapy - visualise pancreatic and biliary tree - strictures/blocks detect - crush stones - stents to restore bile flow

Question 39

Transjugular Intrahepatic Portosystemic Shunt

Answer 39

Small shunt between portal vein and hepatic vein via catheter through jugular vein Reduced portal pressure To embolise varices in recurrent variceal bleed For ascites refractory to medical therapy

Question 40

Downside of transjugular intrahepatic portosystemic shunt

Answer 40

Forces portal into systemic circulation via manmade shunt so increases risk of hepatic encephalopathy