Deranged Liver Function
at the bedside
- vitals: septic, encephalopathic, or bleeding?
- assess jaundice, asterixis, conscious level, abdominal tenderness
- review drug chart (paracetamol, anti-TB, statins, co-amoxiclav, flucloxacillin, antiepileptics), alcohol, recent procedures
- confirm pattern, compare with previous LFTs
escalate now if
- INR >1.5 or rising
- encephalopathy / asterixis
- hypoglycaemia
- severe jaundice · hypotension
- Charcot’s triad (fever + jaundice + RUQ pain)
interpret the pattern
pattern at a glance
ALT / AST ↑ → hepatocellular
ALP / GGT ↑ → cholestatic
INR / albumin abnormal → synthetic dysfunction
ALP / GGT ↑ → cholestatic
INR / albumin abnormal → synthetic dysfunction
- hepatocellular (ALT/AST > ALP): viral, drugs / paracetamol, ischemic (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 to paracetamol, ischemic hepatitis, acute viral, autoimmune
focused check
HPI
- hepatocellular: viral risk, alcohol, drug injury, autoimmune
- cholestatic: RUQ pain, jaundice, pale stools, dark urine, pruritus
- chronic liver disease: ascites, GI bleeding, encephalopathy, weight loss
- meds: paracetamol, statins, antibiotics, herbals, antiepileptics
examination
- general: jaundice, cachexia, confusion
- chronic liver disease: spider naevi, palmar erythema, gynaecomastia, ascites, splenomegaly
- abdomen: hepatomegaly, RUQ tenderness, Murphy’s sign
send now
- synthetic function: INR, albumin, glucose (define severity, not transaminases)
- viral hepatitis serology, paracetamol level (+ timed level if overdose)
- USS abdomen: biliary dilatation, liver texture, portal flow; MRCP if obstruction suspected
- if cause unclear: autoimmune screen, ferritin, ceruloplasmin (selected)
if abdominal pain, add lipase
- pancreatitis if >3× ULN with consistent pain; lipase cleaner than amylase (also rises in bowel ischemia, perforation, DKA, renal failure)
treat
- stop the hepatotoxic drug; treat the cause
- hepatocellular: synthetic failure → discuss with the transplant centre early
- cholestatic: USS; if obstruction, biliary decompression (ERCP); GI / hepatology review
acute liver failure
- rising INR + falling albumin + encephalopathy + hypoglycaemia
- urgent hepatology / ICU
- N-acetylcysteine if paracetamol-related (start before levels if staggered or late presentation):
- bag 1: 150 mg/kg in 200 mL glucose 5% IV over 1 h
- bag 2: 50 mg/kg in 500 mL glucose 5% IV over 4 h
- bag 3: 100 mg/kg in 1000 mL glucose 5% IV over 16 h
- anaphylactoid reactions common (flushing, urticaria, bronchospasm): slow infusion, give antihistamine; do not stop NAC unless true anaphylaxis
- follow local toxicology / pharmacy protocol for obesity dosing and treatment beyond 21 h
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 ascites
calculator MELD-Na · MDCalc ↗︎
recheck
- INR, albumin, glucose define severity: trend them, not just transaminases
- repeat LFTs to confirm trend, not a single value
before leaving
- document: pattern (hepatocellular / cholestatic / mixed), suspected cause, synthetic function
- pending: repeat LFTs, viral serology, imaging sent
- hand over: INR / encephalopathy trend, escalation trigger for acute liver failure
MOC pearl
transaminases give the pattern; INR, albumin and glucose give the severity. rising INR with encephalopathy = acute liver failure: call hepatology.
evidence
| source | type |
|---|---|
| R-factor (R-ratio) pattern classification | common practice |
| IV N-acetylcysteine 3-bag (Prescott) protocol for paracetamol toxicity | established protocol / BNF |
Verify indication, dose, allergies, interactions, renal/hepatic function and local protocols before prescribing.
go deeper MOC+ Vol 4 · Acute GI & Hepatology covers this in the full reference. or the complete set.
free the on-call checklist covers the whole shift on one printable page.
More clinical resources in the MOC+ Library →
updated Sep 2026file lab/lft-liver-function