1. Evaluation of Abnormal Liver Tests
Timothy R. Morgan

2. Outline What are Liver Tests?
Where in the liver do the “Liver Tests” come from?
Normal values
Tests of “liver function” vs. “liver injury”
Three questions!
Hepatocellular vs. Obstructive
Common causes of hepatocellular and obstructive
Work-up algorithm
Evaluation of severity of liver disease

3. Liver Tests Bilirubin, total, direct <1.2 / <0.3 mg/dL
Albumin – 4.8 g/dL
Aspartate aminotransferase (AST) 10 – 32 IU/mL
Alanine aminotransferase (ALT) 3 – 30 IU/mL
Alkaline phosphatase 30 – 115 IU/mL
Gamma glutamyltransferase 2 – 65 U/mL

4. Normal Liver: H&E Stain
Hepatocyte
AST
ALT
Albumin
INR
Bilirubin
Cerulo
α-1 AT
THV
Bile
Ducts
Alk
Phos
GGT
Bilirubin
Portal
Vein
Bile
Duct
Portal
Portal

5. Marker of injury, not function !
Liver Blood Tests
Markers of Cell Injury
AST
ASpartate aminoTransferase
Also known as Serum Glutamic-Oxaloacetic Transaminase (SGOT)
AST found in heart, skeletal muscle, brain, gastric mucosa, kidney, pancreas, spleen, lung, and red blood cells
90% of AST in blood is released from liver.
ALT
ALanine aminoTransferase
Also known as Serum Glutamic-Pyruvic Transaminase (SGPT)
ALT found predominantly in liver, very small amounts in kidney and muscle
Almost all ALT in blood is released from the liver
Both are key enzymes in converting amino acids into high energy molecules for gluconeogenesis
Both are intra-cellular enzymes – when their levels increase in the blood, it means that cells are dying
Marker of injury, not function !

6. Markers of Cholestasis
Liver Blood Tests
Markers of Cholestasis
Alkaline Phosphatase
Found in liver, bone, gut, and placenta
Source of alk phos confirmed by elevations in Gamma Glutamyl Transferase (GGT)
Predominantly on the canalicular membrane of the hepatocyte
Alk phos enzyme is induced by elevated levels of bile acids, which can occur either from bile duct obstruction or hepatocyte injury/dysfunction
Total Bilirubin
Comprised of both Conjugated (direct) and Unconjugated (indirect) bilirubin
Bilirubin is produced during the breakdown of hemoglobin
Conjugation occurs in the hepatocyte
Bilirubin rises due to over production (i.e.. hemolysis), under secretion (i.e.. biliary obstruction, liver injury, shunt), or impaired metabolism (i.e.. Gilbert’s syndrome)
Often referred to as “cholestatic enzymes”
Reflect issues surrounding hepatic secretory function

7. Markers of Impaired Synthetic Function
Liver Blood Tests
Markers of Impaired Synthetic Function
Albumin
Blood protein that is made in the liver
Half life of endogenous albumin is days (compared to T½ of infused albumin, which is ~8 hours)
Production is inhibited by physiologic stress (surgery, infection, acute disease)
Production is inhibited in advanced stages of chronic liver disease
INR
Reflects clotting cascade function of the extrinsic clotting pathway (factors II, V, VII, X)
All extrinsic factors made by the liver
Factors II, V, VII are also Vitamin K dependent
Rise in INR reflects deficient production of at least one of the cofactors (in absence of vitamin K deficiency)
Factor VII has the shortest half life of all the cofactors (3 hrs), and is a reasonable measure of immediate liver function
These are true “liver function” tests

8. Liver Function vs. Liver Injury
Bilirubin, total, direct
Albumin
INR
Liver Injury
AST
ALT
(GGT)
(alk phos)

9. Three Questions!! What is the cause of the liver test abnormalities?
How “bad” is the liver injury?
What are we going to do about it?

10. What is the cause of liver injury?
History
Alcohol use, medications, IVDU, past abnormal liver tests, past jaundice, family history, PE
Itching, jaundice, liver size/firmness, spleen
Spider angioma, ascites, encephalopathy
Lab Tests
Liver panel, comprehensive metabolic panel
CBC with diff
INR

11. Hepatocellular vs. Obstructive
AST and ALT
alkaline phosphatase and bilirubin
“Obstructive”
alkaline phosphatase, bilirubin and GGT
AST and ALT

12. Common Causes of Hepatocellular Injury (AST and ALT)
Viral hepatitis (A, B, C) HBsAg, anti-HCV, PCR
Alcohol History, blood alcohol
Drugs/medications history, stopping drug
Fatty Liver BMI, FBS, TG, DM
Autoimmune ANA, SMA
Hemochromatosis Iron/TIBC/Ferritin, HFE
Wilson disease Ceruloplasmin
Alpha-1 antitrypsin deficiency level, phenotype
CHF, ischemic history, time

13. Hepatocellular Injury Raised ALT and AST
History Physical Examination
Age, gender chronic liver disease
Travel, (firm liver, spleen palp)
Medications weight
Alcohol, IVD
Transfusions
HCV Ab ANA Iron/TIBC Ceruloplasmin Alpha-1 AT
HBsAg SMA Ferritin level
HCV-PCR HFE gene phenotype
Liver Biopsy

14. “Obstructive” Bilirubin and Alkaline Phosphatase
Choledocholethiasis (Common bile duct stones)
Cancer with obstruction of CBD (pancreatic, cholangiocarcinoma, gallbladder)
Cancer metastatic to liver (e.g., colon, pancreas)
Mass in liver (granulomas, abscess)
Drug injury (cholestasis)
Primary biliary cirrhosis
Sclerosing cholangitis
Third trimester of pregnancy

15. Diagnostic Tests for Obstructive
Ultrasound of liver, gallbladder pancreas, bile ducts
CT, MRI
Endoscopic retrograde cholangiopancreatography,
Endoscopic ultrasound
Antimitochondrial antibody (AMA)
Liver biopsy

16. Alkaline Phosphatase, Bilirubin, GGT
“Obstruction”
Alkaline Phosphatase, Bilirubin, GGT
History Physical Examination
Age, gender chronic liver disease
Jaundice (firm liver, spleen palp)
Medications weight
Weight loss, itching
AMA US, CT, MRI
AMA +
Liver Biopsy
Mass or
Non-dilated Ducts
Liver Biopsy
Dilated Bile Ducts
ERCP / EUS

17. How Bad is the Liver Disease?
History
Ascites, variceal bleeding, encephalopathy
Physical Examination
Firm liver, splenomegaly
Spider angiomas, palmar erythema
Ascites, hepatic encephalopathy
Laboratory tests
Albumin, bilirubin (direct), INR
Platelet, WBC
Liver Biopsy

19. Stages of Fibrosis In Chronic Hepatitis
HCV - Natural History
Stages of Fibrosis In Chronic Hepatitis
Portal
Periportal
Septal
Cirrhosis 1 2 3 4
Slide 202
Stages of Fibrosis In Chronic Hepatitis
Most pathologist use a four-point system for staging fibrosis in chronic hepatitis, based on the amount of fibrosis seen in relation to the portal tract [Desmet VJ et al., Hepatology 1994;19:1513].
In stage 1, an increased amount of collagen expands the portal area.
In stage 2, strands of fibrosis extend out from portal areas but do not interconnect.
In stage 3, strands of fibrosis begin to connect from one portal tract to another, forming septa.
In stage 4, or cirrhosis, the septa have formed a network of interconnecting bands surrounding nodules of liver cells. At this point, the original architecture of the liver has been completely transformed.
(The Metavir Scoring System is described in more detail in slide 364.)
Photo courtesy of Tom Smyrk, MD, Mayo Medical Center, Rochester, MN

20. What are we going to do about the liver disease?
Depends on cause of liver disease, severity of liver disease and patient’s wishes

21. Case 1 23 yo Asian male college student.
Maternal grandmother died of liver disease
No alcohol use, no IVDU
Not on any medicines, no prior history of liver disease PE
Liver palpable, slightly firm

22. Case 1 Lab tests AST 84 IU/mL ALT 129 IU/mL
Alkaline phosphatase 114 IU/mL
Total bilirubin IU/mL
Direct bilirubin IU/mL
Albumin g/dL
Total protein g/dL

23. Case 1 HBsAg positive Hepatitis C antibody negative
Iron/TIBC/Ferritin 98/278/351
ANA negative
Alpha-1 antitrypsin 159 (normal)
Ceruloplasmin 33 (normal)

24. Case 3
32 yo man was at health fair and had blood tests showing elevated ALT and AST
No prior liver disease, no medications, no family history of liver disease, no IVDU
Drinks 2-3 beers on weekend days
PE: normal

25. Case 3 Lab tests AST 61 IU/mL ALT 88 IU/mL
Alkaline phosphatase 78 IU/mL
Bilirubin T/D / 0.1 mg/dL
Albumin mg/dL

26. Case 3 differential Diagnosis
Viral hepatitis
Drugs
Alcohol
Hemochromatosis
Wilson disease
Alpha-1 antitrypsin deficiency
Autoimmune disease

27. Case 3: Test Results HBsAg negative HCV antibody negative ANA negative
Alpha-1 antitrypsin normal
Ceruloplasmin normal
Iron/TIBC/Ferritin 289/305/1740
HFE gene double mutation of C282Y

28. Hemochromatosis
(Prussian Blue Stain

29. Case 4
23 yo female office assistant seen in ER for severe headache. Elevated ALT
No personal or family history of liver disease, no IVDU, no abdominal pain
3-4 drinks/day on weekends
OCP
PE: ?? Palpable spleen, otherwise normal

30. Case 4 Lab results AST 91 IU/mL ALT 133 IU/mL
Alkaline phosphatase 145 IU/mL
Bilirubin T/D / 0.4 IU/mL
Albumin IU/mL
Total protein IU/mL

31. Case 4: Differential Diagnosis
Alcohol
Viral hepatitis
Medications
Autoimmune
Hemochromatosis
Wilson
Alpha-1 antitrypsin deficiency

32. Case 4 Test Results HBsAg negative Hepatitis C antibody negative
Iron/TIBC/Ferritin 68/389/154
Ceruloplasmin 66
Alpha-1 antitrypsin normal
ANA 1:320
Smooth muscle antibody 1:64

33. Autoimmune Hepatitis
Mieli-Vergani, G. & Vergani, D. (2011) Autoimmune hepatitis
Nat. Rev. Gastroenterol. Hepatol. doi: /nrgastro

34. Case 5
48 yo female with mildly abnormal liver tests for past few years
Medications for Maxide and simvastatin, estrogen
Alcohol 1 drink/day, no IVDU, or surgery,
Mother had hypertension, father had diabetes and MI
PE: BMI 31

35. Case 5 Labs AST 53 IU/mL ALT 69 IU/mL Alkaline phosphatase 154 IU/mL
Bilirubin T/D / 0.2
Albumin g/dL
Total protein g/dL
Triglycerides
Glucose mg/dL

36. Case 5 Differential Diagnosis
Viral hepatitis
Alcohol
Fatty liver
Autoimmune
Hemochromatosis
Alpha-1 antitrypsin
Wilson
Medications

37. Case 5 Test Results HBsAg negative Hep C antibody and PCR negative
Iron/TIBC/Ferritin 126/349/233
ANA and SMA negative
Ceruloplasmin normal
Alpha-1 antitrypsin normal
Glucose mg/dL
Insulin elevated (2x)

38. Steatosis THV THV: terminal hepatic venule
The lesions of NASH in adults (without bridging or advanced fibrosis) are predominantly in zone 3 as noted by the terminal hepatic venule. The steatosis, as seen here, may be mixed macro and smalldroplet or microvesicular steatosis.
THV: terminal hepatic venule

39. Case 6 45 yo asymptomatic woman. No history of alcohol use or IVDU.
No prescription meds. Occasionally takes acetaminophen, ibuprofen, and various alternative meds.
Normal physical examination

40. Case 6 (lab tests) Total Bilirubin 1.2 mg/dl
Direct Bilirubin 0.3 mg/dl
Alkaline phosphatase 437 IU/mL
AST IU/mL
ALT IU/mL
Albumin g/dL
Total protein g/dL

41. Case 6 Differential Diagnosis
Choledocholethiasis
Drugs
Primary biliary cirrhosis
Metastatic disease to liver
Granulomas in liver
Ultrasound of liver and bile ducts
Antimitochondrial antibody

42. Primary Biliary Cirrhosis
(Florid Duct Stage)

43. Case 7
66 yo man with 20 lb weight loss who says his eyes turned yellow yesterday.
No prior liver disease, 1-2 drinks per day,
Uncle had colon cancer, mother had breast cancer
PE: jaundice, mildly tender RUQ

44. Case 7 Lab Tests AST 98 IU/mL ALT 112 IU/mL Albumin 3.5 g/dL
Bilirubin (T/D) / 5.5 mg/dL
Alk phos U/mL
GGT U/mL

45. Case 7 Differential Dx Biliary tract obstruction Pancreatic cancer
Cholangiocarcinoma
Choledocholethiasis (CBD stone)

46. ERCP
Double-Duct Sign

47. Case 8 25 yo man with depression
Uses multiple drugs: heroin, ecstasy, methamphetamine, marijuana; most recently several days prior to admission
No significant alcohol use
No regular medications
PE: normal

48. Case 8 Lab Tests AST 2150 IU/mL ALT 2005 IU/mL Alk Phos 78 IU/mL
Bilirubin T/D 4.3/1.4 mg/dL
Albumin g/dL
T. Protein g/dL
INR
Creatinine mg/dL

49. Case 8: Differential Diagnosis
Acute viral hepatitis (A, B, C, E)
Drug toxicity (Acetaminophen)
Ischemic hepatitis
Autoimmune hepatitis
Wilson disease

50. Case 8: Lab Results HBsAg Negative HBcAb-IgM Negative
Hepatitis A-IgM Negative
Hepatitis C Ab Negative
Hepatitis C PRC Negative
ANA Negative
Ceruloplasmin 22 (normal: 20 – 60)
Acetaminophen 87

51. Case 2 67 yo man No alcohol or tobacco, no IVDU
no family history of liver disease
lisinopril and simvastatin PE
Unremarkable

52. Case 2 Lab Tests AST 35 IU/mL ALT 78 IU/mL
Alkaline phosphatase 106 IU/mL
Bilirubin T/D / 0.2 mg/dL
Albumin mg/dL

53. Case 2 Differential Diagnosis
Hepatitis B,
Hepatitis C
Hemochromatosis
Wilson, autoimmune, drugs
Alpha-1 antitrypsin deficiency

54. Case 2 Test results HBsAg negative Hepatitis C antibody negative
Negative HCV-RNA
Iron/TIBC/Ferritin 189/402/255
ANA negative
Ceruloplasmin normal
Alpha-1 antitrypsin 39 (90-199)
Phenotype S/Z

55. Alpha-1 antitrypsin
Liver Histology

56. Three Questions!! What is the cause of the liver test abnormalities?
How “bad” is the liver injury?
What are we going to do about it?

57. Hepatocellular vs. Obstructive
AST and ALT
alkaline phosphatase and bilirubin
“Obstructive”
alkaline phosphatase, bilirubin and GGT
AST and ALT

58. Common Causes of Hepatocellular Injury (AST and ALT)
Viral hepatitis (A, B, C) HBsAg, anti-HCV, PCR
Alcohol History, blood alcohol
Drugs/medications history, stopping drug
Fatty Liver BMI, FBS, TG, DM
Autoimmune ANA, SMA
Hemochromatosis Iron/TIBC/Ferritin, HFE
Wilson disease Ceruloplasmin
Alpha-1 antitrypsin deficiency level, phenotype
CHF, ischemic history, time

59. Hepatocellular Injury Raised ALT and AST
History Physical Examination
Age, gender chronic liver disease
Travel, (firm liver, spleen palp)
Medications weight
Alcohol, IVD
Transfusions
Anti-HCV ANA Iron/TIBC Ceruloplasmin Alpha-1 AT
HBsAg SMA Ferritin level
HCV-PCR HFE gene phenotype
Liver Biopsy

60. “Obstructive” Bilirubin and Alkaline Phosphatase
Drug injury (cholestasis)
Choledocholethiasis (Common bile duct stones)
Cancer with obstruction of CBD (pancreatic, cholangiocarcinoma, gallbladder)
Cancer metastatic to liver (eg, colon, pancreas)
Mass in liver (granulomas, abscess)
Primary biliary cirrhosis
Sclerosing cholangitis
Women in third trimester

61. Alkaline Phosphatase, Bilirubin, GGT
“Obstruction”
Alkaline Phosphatase, Bilirubin, GGT
History Physical Examination
Age, gender chronic liver disease
Jaundice (firm liver, spleen palp)
Medications weight
Weight loss, itching
AMA US, CT, MRI
AMA +
Liver Biopsy
Mass or
Non-dilated Ducts
Liver Biopsy
Dilated Bile Ducts
ERCP

62. “Liver Function” Tests
Bilirubin, total, direct
Albumin, (total protein [globulin])
Aspartate aminotransferase (AST)
Alanine aminotransferase (ALT)
Alkaline phosphatase
Gamma glutamyltransferase
INR
Platelets
WBC, MCV, hemoglobin

63. “Liver Injury” Tests Bilirubin, total, direct
Albumin, (total protein [globulin])
Aspartate aminotransferase (AST)
Alanine aminotransferase (ALT)
Alkaline phosphatase
Gamma glutamyltransferase
INR
Platelets
WBC, MCV, hemoglobin

64. Globulins (total protein – albumin)
Made by liver
Decreased due to low production (cirrhosis), loss through kidney (nephrotic syndrome), catabolism (burns, malnutrition) and increased total body water (cirrhosis)
Globulins (total protein – albumin)
Elevated in multiple myeloma, autoimmune liver disease, cirrhosis of many causes,
If elevated, order SPEP, UPEP

65. Gamma glutamyltransferase (GGTP)
Alkaline phosphatase
Found on bile canniculus and in bone
Increased in bile duct obstruction, masses in liver (mets, granuloma) and bone disease
Gamma glutamyltransferase (GGTP)
Specific to liver
Increased in alcohol use, bile duct obstruction, masses in liver

66. AST and ALT Aspartate aminotransferase (AST)
Found in mitochondria and in cytosol
Increased in many liver disease
muscle injury (MI, rhabdomyolysis)
Alanine aminotransferase (ALT)
Found in cytosol
“specific” to liver
Elevated in many liver disease with inflammation and liver cell death

67. Diagnostic Tests for Hepatocellular
AST to ALT ratio
AST> ALT usually alcohol use
ALT>AST all other causes (viral hepatitis)
HBsAg, Hep C antibody, HCV-PCR,
IgM Hepatitis A
Antinuclear antibody (ANA), smooth muscle antibody (SMA)
Iron, TIBC, ferritin, HFE gene (hemochromatosis)
Ceruloplasmin
Alpha-1 antitrypsin level and phenotype

68. Case 2 Asian Family history of liver disease ?? Firm liver
Elevated ALT>AST
DDx
Chronic viral hepatitis (B or C)
Hemochromatosis
Wilson, Alpha-1 antitrypsin,

69. (Liver Biopsy, Masson Trichrome Stain
Cirrhosis
(Liver Biopsy, Masson Trichrome Stain

70. Normal Values AST 10 – 32 U/L ALT 3 – 30 U/L
Bilirubin T/D <1.3 / <0.3
Alk Phosphatase 35 – 105 U/L
GGT – 65 U/L
Albumin
Ceruloplasmin 40 – 80
Alpha-1 AT – 199

71. ERCP
Double-Duct Sign

72. How Bad is the Liver Disease?
Laboratory tests
Usually normal until patient develops cirrhosis
Platelet count
Bilirubin (especially direct)
Albumin
INR

73. How Bad is the Liver Disease?
Ultrasound and CT usually not helpful
Liver spleen scan
Redistribution to the bone marrow (more important than spleen)
Liver biopsy
Fibrosis
Inflammation
Etiology

74. Autoimmune Hepatitis
Mieli-Vergani, G. & Vergani, D. (2011) Autoimmune hepatitis
Nat. Rev. Gastroenterol. Hepatol. doi: /nrgastro

75. What is the cause of liver injury?
History, PE
Routine Lab tests
Hepatocellular vs. obstructive
“Special” lab tests

76. How Bad is the Liver Disease?
History
Ascites, variceal bleeding, encephalopathy,
Physical Examination
Firm liver, splenomegaly
Spider angiomas, palmar erythema
Ascites, hepatic encephalopathy
Laboratory tests
Albumin, bilirubin (direct), INR
Platelet, WBC
Liver Biopsy

78. Stages of Fibrosis In Chronic Hepatitis
HCV - Natural History
Stages of Fibrosis In Chronic Hepatitis
Portal
Periportal
Septal
Cirrhosis 1 2 3 4
Slide 202
Stages of Fibrosis In Chronic Hepatitis
Most pathologist use a four-point system for staging fibrosis in chronic hepatitis, based on the amount of fibrosis seen in relation to the portal tract [Desmet VJ et al., Hepatology 1994;19:1513].
In stage 1, an increased amount of collagen expands the portal area.
In stage 2, strands of fibrosis extend out from portal areas but do not interconnect.
In stage 3, strands of fibrosis begin to connect from one portal tract to another, forming septa.
In stage 4, or cirrhosis, the septa have formed a network of interconnecting bands surrounding nodules of liver cells. At this point, the original architecture of the liver has been completely transformed.
(The Metavir Scoring System is described in more detail in slide 364.)
Photo courtesy of Tom Smyrk, MD, Mayo Medical Center, Rochester, MN

79. What are we going to do about the liver disease?
Depends on cause of liver disease, severity of liver disease and patient’s wishes