As the FY1, you will see patients with liver dysfunction either on the take or deranged LFTs when you are reviewing bloods. A focused approach can save you time & help you find the likely underlying cause to start investigating. It can also help you identify red flags that prompt urgent escalation.

Red flags (urgent escalation)
  • Haemodynamic instability or worried about a patient
  • Decompensated disease (newly jaundiced, encephalopathic, ascites)
  • Synthetic dysfunction - i.e. deranged clotting, bruising/petechiae/purpura/bleeding
  • Septic
  • Suspicion of paracetamol OD
  • Significant abdominal tenderness
  • Duration
  • Previous episodes
  • Urine/stool colour
  • Painful/painless 
  • Itching
  • Systemic features: weight loss/fever/anaemia/arthralgia/myalgia/rash/fatigue
  • Decompsenation features: abdominal swelling, fogginess, change in skin colour
  • Alcohol intake: CAGE
  • Travel (viral hepatitis/parasitic)
  • Risk factors: IVDU/tattoos/piercings/blood transfusion/MSM/sex workers
  • PMH: biliary surgery/gallstones/hepatitis/thyroid disease/NAFLD
  • Drugs: 
    • Paracetamol & paracetamol containing medication
    • Antibiotics: co-amox/fluclox/tuberculosis treatment
    • statins
    • NSAIDs
    • anticonvulsants
    • methotrexate
    • herbal & OTC remedies
    • oestrogens (contraceptive pill)
  • Family Hx: anaemia/haemoglobinopathies/liver disease
  • Possibility pregnancy (obstetric emergency) - usually occurs late in pregnancy so should be obviously pregnant 
  • Sepsis Sx: tachycardia/hypotension/fever
  • CLD Sx: palmar erythema/spider naevi/gynaecomastia
  • Visible abdominal collaterals
  • Lymphadenopathy
  • Hepato/splenomegaly with any palpable masses
  • Decompensation: jaundice, ascites & encephalopathy (altered neuromuscular function with ataxia/nystagmus/asterixis or altered mental status)
  • Murphy's sign
  • Observations
  • Urine dip
  • FBC (haemolysis/infection/low platelets suggestive of portal hypertension with splenomegaly), U&E (renal impairment), LFTs: cholestatic (GGT; ALP), hepatitic (AST; ALT), split or unconjugated/conjugated bilirubin 
  • Synthetic function: Coagulation screen & albumin
  • Viral hepatitis screen
    • Hepatitis B surface Ag, surface Ab, core Ab
    • Hepatitis C IgG (and if positive viral load/quantitative testing)
    • Hepatitis A & E tend not to be chronic, consider testing if risk factors (travel/faecal-oral)
  • US abdomen (CBD size, liver disease, gallstones, portal vein thrombosis - may need to ask for dopplers specifically)
  • Blood cultures if any features to suggest infection
Advanced investigations (discuss with seniors)
  • Paracetamol levels (unhelpful in staggered overdose, it is safer to treat than not treat if even mildly suspected but discuss with seniors)
  • Immunoglobulins & Autoantibodies (on the advice of seniors)
  • Ferritin (ferritin is frequently raised in the absence of haemochromatosis, may not be helpful)
  • Alpha 1 antitrypsin (only in the context of respiratory disease or if suspicion for other reasons)
  • Alpha-fetoprotein (it is usually cirrhotics who get HCC, so rarely any point doing if they're not known cirrhotic)
  • Caeruloplasmin (really rare!)
  • TFTs (have a low threshold to do TFTs)
  • EBV/CMV serology
  • MRCP/ECRP & CT imaging (very much guided by seniors!)
This depends on the underlying cause as one would expect however it is a good idea to discuss each case with your seniors

Are they cirrhotic? 
  • Do they have features to suggest splenomegaly or chronic liver disease? 
  • Do they need surveillance for varices?
  • Do they have features of decompensation
    • Ascites - US abdomen (to confirm unless obvious) & discuss with seniors with a view to referring to a gastroenterologist for consideration of tap for SBP, malignancy etc. & diuretics for excess fluid
    • Encephalopathy - aim for 3 soft stools per day with as much lactulose & phosphate enemas as is required & discuss with seniors with a view to referring to a gastroenterologist
    • Deranged clotting - unless contraindications, they require high dose vitamin K/phytomenadione (e.g. 10mg IV once daily for 3 days) based on local guidelines and if no contraindications. Note this doesn't correct the deranged clotting if it is due to the liver, it simply treats an underlying vitamin K deficiency to unmask if it is truly due to liver dysfunction
Pre-hepatic (unconjugated hyperbilirubinaemia) 
  • consider haemolysis or a haemoglobinopathy (are they anaemic? blood film? splenomegaly?)
  • Infective causes of haemolysis usually will be obvious as the patient is quite unwell & will need discussion with seniors & management of sepsis
  • Viral hepatitis, NAFLD & alcohol are by far the most common
    • Viral hepatitis - diagnose and refer to gastroenterology
    • NAFLD - aim for 10% weight reduction. discuss with gastroenterology about follow up and liver elastography
    • Alcohol - refer to the substance misuse team
  • About 3% of the population have Gilbert's disease where intracellular conjugation is impaired which therefore causes an isolated unconjugated hyperbilirubinaemia. This is hereditary and usually requires no treatment
  • Drug-induced liver disease is also quite common in hospital - carefully look at each drug in the BNF or contact the ward pharmacist. Be vigilant for paracetamol overdose & stop any offending drugs if it is safe to do so
  • Cirrhosis from any cause
    • If one of the rarer or inherited 
Post hepatic
  • If you suspect a post hepatic cause then escalation is always appropriate
  • If painful or infective looking, always consider cholangitis. Manage this as you would any septic patient but with urgent escalation for consideration of MRCP/ERCP
  • If painless, always consider pancreatic cancer or another malignant process
  • Always think about portal vein thrombosis (again urgently escalate)
Further reading
By Dr Ashleigh Draper
Edits & additions by Dr Akash Doshi CT2