Deranged Liver Function
ABCs
red flags
- INR >1.5 or rising
- encephalopathy / asterixis
- hypoglycaemia
- severe jaundice · hypotension
- Charcot’s triad (fever + jaundice + RUQ pain)
- check vitals: is the patient septic, encephalopathic, or bleeding?
- assess jaundice, asterixis, conscious level, abdominal tenderness
- review the drug chart (paracetamol, anti-TB, statins, co-amoxiclav, flucloxacillin, antiepileptics), alcohol, recent procedures
- confirm the pattern, compare with previous LFTs
pattern at a glance
ALT / AST ↑ → hepatocellular
ALP / GGT ↑ → cholestatic
INR / albumin abnormal → synthetic dysfunction
ALP / GGT ↑ → cholestatic
INR / albumin abnormal → synthetic dysfunction
read the pattern
- hepatocellular (ALT/AST > ALP): viral, drugs / paracetamol, ischaemic (shock liver), alcohol (AST:ALT >2:1), autoimmune
- cholestatic (ALP/GGT > ALT): obstruction (stones, tumour), drug-induced, PBC / PSC
- mixed (both raised): drugs, sepsis, infiltration
- isolated bilirubin (rest normal): unconjugated = Gilbert’s / haemolysis, conjugated = biliary
tools
- R factor (ALT/ULN) / (ALP/ULN): >5 hepatocellular, <2 cholestatic, 2 to 5 mixed
- transaminases >1000: narrow it: paracetamol, ischaemic hepatitis, acute viral, autoimmune
HPI
- hepatocellular: viral risk factors, alcohol, drug-induced injury, autoimmune disease
- cholestatic: RUQ pain, jaundice, pale stools, dark urine, pruritus
- chronic liver disease: ascites, GI bleeding, encephalopathy, weight loss
- meds: paracetamol, statins, antibiotics, herbal supplements, antiepileptics
examination
- general: jaundice, cachexia, confusion
- chronic liver disease: spider naevi, palmar erythema, gynaecomastia, ascites, splenomegaly
- abdomen: hepatomegaly, RUQ tenderness, Murphy’s sign
workup
- synthetic function: INR, albumin, glucose (these define severity, not the transaminases)
- viral hepatitis serology, paracetamol level (+ a timed level if overdose)
- USS abdomen: biliary dilatation, liver texture, portal flow; MRCP if biliary obstruction suspected
- if the cause is unclear: autoimmune screen, ferritin, ceruloplasmin (selected)
if abdominal pain, add a lipase
- pancreatitis if >3× ULN with consistent pain; lipase is cleaner than amylase (which also rises in bowel ischaemia, perforation, DKA, renal failure)
management
- treat the cause, stop the hepatotoxic drug
- hepatocellular: treat the cause (viral, autoimmune, ischaemic); with synthetic failure, discuss with a transplant centre early
- cholestatic: USS; if obstruction, biliary decompression (ERCP); GI / hepatology review
- monitor INR, albumin, glucose: not just the transaminases
acute liver failure
- rising INR + falling albumin + encephalopathy + hypoglycaemia
- urgent hepatology / ICU; N-acetylcysteine if paracetamol-related (start before levels if staggered or late)
ascending cholangitis: Charcot’s triad
- fever + jaundice + RUQ pain
- IV antibiotics + urgent biliary drainage (ERCP)
new ascites + confusion in known liver disease
- think SBP and hepatic encephalopathy: tap the ascites
calculator MELD-Na · MDCalc ↗︎
MOC pearl
the transaminases give you the pattern; INR, albumin and glucose give you the severity. a rising INR with encephalopathy = acute liver failure: call hepatology.
MOC+ Volume 4 GI / Hepatology goes deeper on the cirrhotic and the bleeding liver patient. see the library.
Last reviewed · June 2026