Editor and reviewer:  Ken Liu

Contributor: May Wong

 

In a hurry? Make sure you know

  • The pattern of liver injury. If serum enzymes affected: hepatocyte damage (ALT, AST) vs cholestasis (ALP, GGT, Bilirubin) vs mixed. While these can give you a clue towards the underlying aetiology, liver insults may not always present in the expected pattern, so keep an open mind!
  • Is synthetic function affected? (INR, albumin)

 

What history should  JMOs know / collect?

  • Medications especially any new ones (don’t forget TPN, OCP, herbal and over the counter meds)
  • Alcohol history
  • Risk factors for viral hepatitis e.g. Ethnicity, Hx of IVDU

 

What examinations and investigations should JMOs perform/collect results of?

  • Examination findings: signs of chronic liver disease, decompensation, portal hypertension, right heart failure, BMI
  • Note if a patient is newly encephalopathic call the gastroenterology registrar immediately
  • Sepsis, hypotension or right heart failure can also cause deranged LFTs
  • Liver panel

 


Viral

Hepatitis BsAg, Hepatitis BcAb, Hepatitis BsAb

If HBsAg positive, add Hep BeAg, eAb, and HBV DNA

Hepatitis C core Ab

If positive, add HCV RNA and genotype

If acute hepatitis: HAV IgM, HBV Core IgM, EBV and CMV IgM

 

Autoimmune

AMA (primary biliary cholangitis)

ANA/Smooth muscle antibody/ anti LKM (autoimmune hepatitis)

Immunoglobulin A, G, M levels (autoimmune hepatitis)

 

Panadol level

 

Others – Think before ordering as it is rare for these to present for the first time as deranged LFTs in an inpatient

Iron studies

Caeruloplasmin and serum copper (don’t do if over age 40)

Alpha 1 anti trypsin levels

Conjugated bilirubin +/- haemolysis screen

 


 

  • Ammonia level if relevant (e.g. Encephalopathic)
  • Ascitic tap (incl albumin/protein/WCC + differential)
  • Relevant imaging e.g.: Liver ultrasound or CT triple phase scan or MRCP

 

What additional information would impress you?

  • Trajectory of liver test derangement (e.g. Have outpatient ones to compare with)
  • Calculation of patient’s Child Pugh or MELD score
  • JMOs coming up with their differentials along with information that supports or disproves their case

 

What are common mistakes/omissions made by JMOs?

  • Not thinking about what pattern of liver damage
  • Forgetting extra hepatic causes such as cholestasis of sepsis, heart failure, ischaemic hepatitis, and haemolysis
  • If they don’t know already, ALWAYS inform the liver transplant team if a transplant patient has been admitted under you (even if it is for a non-transplant issue)

 

Helpful resources

  • The junior doctor’s friendly gastroenterology or liver registrar
  • See attached paper for the budding gastroenterology trainee

 

Podcasts

Volovets, Anastasia.  (2015).  Chronic liver disease.  [podcast].  Available at:  https://onthewards.org/chronic-liver-disease/  [Accessed 3 February 2015]

Liu, Ken.  (2015).  Liver function tests.  [podcast].  Available at:  https://onthewards.org/liver-function-tests/ [Accessed 2 September 2015]

Volovets, Anastasia.  (2017).  Liver transplantation.  [podcast].  Available at:  https://onthewards.org/liver-transplantation/ [Accessed 29 November 2017]