Abnormal Liver Function Tests (LFT)

Liver function tests are a type of blood test that measure levels of certain enzymes and proteins made by the liver.
These tests are ordered for people with symptoms of liver problems, as part of routine blood work, to monitor the safety of certain medications or to track the progression of certain illnesses.

Ascites

Overview

Ascites is a condition where fluid accumulates in the peritoneal or abdominal cavity.  It is most commonly seen in patients with cirrhosis of the liver; however, ascites can also be present in patients with severe congestive heart failure, cancer, or an infection such as tuberculosis.

Symptoms

Patients with ascites typically complain of distention of the abdomen.  This may result in difficulty breathing and a poor appetite.  It is often seen in association with generalized fluid retention and swelling of the lower extremities.

Testing

The diagnosis of ascites is typically made on the basis of physical examination.  An imaging study of the abdomen, such as an ultrasound or CAT scan will typically be performed to confirm the diagnosis.  Fluid may be removed from the abdominal cavity through a procedure known as paracentesis.  A needle is inserted into the peritoneal cavity and fluid is removed for chemical analysis.  A large quantity of fluid may also be removed to eliminate symptoms caused by the abdominal extension.

Treatment

Treatment of ascites is dependent on the underlying cause.  Patients with cirrhosis of the liver, ascites can often be managed by restriction of salt intake and diuretic medications.  Fluid accumulation refractory to these measures may require periodic paracentesis to remove large volumes of fluid.  Occasionally, a patient will require a shunt to allow blood to flow more efficiently through the scarred and cirrhotic liver.

Autoimmune Hepatitis

Overview

Autoimmune hepatitis is a disease of the liver that occurs when the body’s immune system inappropriately attacks the cells of the liver.  It affects women much more commonly than men.  It is often associated with other autoimmune disorders.

Symptoms

Patients often present with jaundice, or yellowing of the eyes and skin.  They may experience generalized fatigue, itching and discomfort in the right upper abdomen.  Other patients may have no symptoms and the disease may only be evident by the presence of abnormal liver enzymes in the blood.

Testing

Diagnosis of autoimmune hepatitis is initially made by looking for antibodies in the blood associated with this condition.  These include antinuclear antibody, antismooth muscle antibody and anti liver kidney microsomal antibody.  A liver biopsy may also be necessary to confirm the diagnosis and to assess the degree of inflammation and/or scarring present within the liver.

Treatment

Treatment typically involves the prescription of immune suppressing drugs, such as steroids or Azathioprine.  Chronic treatment is often necessary as the disease will frequently relapse when medical therapy is discontinued.

Cirrhosis

Overview

Cirrhosis is the end stage of chronic liver disease.  It is characterized by the replacement of the normal liver with scar tissue.  Common chronic liver diseases which can result in cirrhosis include alcoholism, viral hepatitis, fatty liver disease, and autoimmune forms of chronic liver disease.

Symptoms

Symptoms of cirrhosis result from the inability of the liver to perform its normal function.  Scarring also prevents normal blood flow through the liver and excretion of bile into the intestine.  Patients often develop yellowing of the skin or eyes, known as jaundice.  Fluid may accumulate in the abdominal cavity and lower extremities.  Accumulation of blood toxins in the brain may result in confusion, a condition known as hepatic encephalopathy.  Enlarged veins may develop in the esophagus and stomach known as varices.  These can rupture and produce severe gastrointestinal bleeding.  This may be evidenced by vomiting blood or passing bloody stools.

Testing

The diagnosis of cirrhosis is typically made on the basis of symptoms and the physical findings mentioned above.  Patients will often have abnormal laboratory studies.  Imaging studies of the abdomen such as ultrasound, CAT scan or MRI will show the typical characteristic changes of cirrhosis.  A liver biopsy may be necessary to confirm the diagnosis of cirrhosis or to determine a specific underlying cause.

Treatment

Typically the liver damage from cirrhosis cannot be reversed.  An underlying form of chronic liver disease should be identified, as specific therapy may be available to prevent further progression of liver disease.  Specific treatments for symptoms such as hepatic encephalopathy, ascites, and gastrointestinal bleeding are available.  Please refer to these specific conditions for further information.  Ultimately, patients with cirrhosis require liver transplantation to prevent death.

Fatty Liver Disease

Overview

Non-alcoholic fatty liver disease is a condition in which fat accumulates within the liver.  This is known as steatosis.  Accumulation of fat may cause progressive inflammation of the liver or steatohepatitis.  If left untreated, this may eventually result in chronic liver disease or cirrhosis.  Fatty liver disease is seen in patients with obesity, elevated cholesterol and diabetes.  It may also be associated with the use of certain medications.

Symptoms

Most patients with fatty liver disease have no symptoms.  The diagnosis is often entertained when blood tests reveal an elevation in the blood liver enzymes.  Patients may have liver enlargement.  If cirrhosis develops, patients may experience symptoms associated with its complications, such as confusion, abdominal swelling or gastrointestinal bleeding.

Testing

Fatty liver disease is typically diagnosed by the presence of elevated liver enzymes on blood tests.  Appropriate studies are then performed to exclude other potential causes of liver disease.  On ultrasound, the liver is often noted to be bright or ecogenic due to fat deposition in the liver.  A liver biopsy may be performed to determine if inflammation or scarring of the liver is present.

Treatment

At this time there is no specific treatment for non-alcoholic fatty liver disease.  Patients should be encouraged to maintain ideal body weight, avoid alcohol consumption, control elevation in cholesterol and triglycerides, and aggressively treat underlying diabetes mellitus.

Hemochromatosis

Overview

Hereditary hemochromatosis is an inherited disorder characterized by an accelerated rate of intestinal iron absorption and progressive iron deposition in various organs.  It typically begins to become clinically apparent in the third to fifth decades of life. The most common gastrointestinal presentation is an unexplained elevation in blood liver enzymes.   Because of the severe sequelae of this disorder if left untreated early diagnosis before symptoms or signs appear is important

Symptoms

Organs commonly affected by hemochromatosis are the liver, heart, and endocrine glands. Manifestations of the disease may include cirrhosis of the liver, diabetes, heart failure, arthritis and tanning of the skin.  In its early stages the disease may have no symptoms and only be suspected on the basis of abnormal blood tests.

Testing

The diagnosis is made by measuring iron levels in the blood.  A blood test can also be performed to identify the genetic abnormality which is associated with the disease.  A liver biopsy may be necessary to confirm the diagnosis and determine the extent of damage that has been done to the liver. Family members of patients diagnosed with hemochromatosis should be advised to be screened genetically to determine if they are a carrier or if they could develop the disease. This can allow preventative measures to be taken.

Treatment

Treatment consists of removing iron from the body by regularly scheduled phlebotomies, the removal of blood from the body.  When first diagnosed, the phlebotomies may be fairly frequent, perhaps as often as once a week, until iron levels can be brought to within normal range. Once iron and other markers are within the normal range, phlebotomies may be scheduled every other month or every three months.  Patients with hemochromatosis are at increased risk for developing liver cancer and should be monitored closely for this condition

Hepatic Encephalopathy

Overview

Hepatic Encephalopathy is a state of confusion or altered level of consciousness, which results from advanced liver disease.  It is caused by accumulation in the bloodstream of toxic substances that are ordinarily removed by the liver.  It is typically seen in patients with advanced chronic liver disease.

Symptoms

In its mildest form, hepatic encephalopathy may be very subtle and only demonstrated by neuropsychological testing.  As the condition worsens, patients may become forgetful and confused.  They may experience difficulty sleeping.  More severe forms of hepatic encephalopathy may present with severe lethargy and even coma.

Testing

The diagnosis of hepatic encephalopathy is made by confirming underlying chronic liver disease and testing for an elevated ammonia level in the blood.  The condition can also be confirmed by electroencephalography.

Treatment

Encephalopathy is often precipitated by other underlying conditions such as infection, gastrointestinal bleeding, chemical imbalances, and medication side effects.  These conditions should be investigated and treated.  Hepatic encephalopathy will often respond to medication such as lactulose or an antibiotic called rifixamin.  Patients with severe encephalopathy may require protein restriction in the diet.

Hepatitis A

Overview

Hepatitis A is an infectious disease of the liver caused by the hepatitis A virus.  It is typically transmitted from person to person by ingestion of contaminated food or water, or through direct contact with an infected person.  It is most common in developing countries where hygiene standards are poor.  Hepatitis A produces a self-limited disease in most people and does not go on to chronic infection or cirrhosis.  In rare cases, acute hepatitis A can be severe and result in acute liver failure.

Symptoms

Symptoms of hepatitis A typically do not occur for two to six weeks after the initial infection.  This is known as the incubation period.  Symptoms may be vague and non-specific.  They include fatigue, fever, nausea and vomiting, yellowing of the skin or eyes (jaundice), dark urine or light colored stools.

Testing

The diagnosis of hepatitis A is initially suspected when symptoms are present and the liver enzymes in the blood are markedly elevated.  Specific blood tests can be performed, which demonstrate an antibody or immune response to the hepatitis A virus.  X-rays or a liver biopsy are not typically required.

Treatment

There is no specific treatment for hepatitis A.  Rest and symptomatic therapy are indicated.  Recovery will occur slowly over several weeks.  The disease can be prevented through appropriate vaccination.

Hepatitis B

Overview

Hepatitis B is an infectious illness of the liver caused by the hepatitis B virus.  It is transmitted by exposure to infectious blood or body fluids.  Risk factors include intravenous drug use, blood transfusion, sexual exposure, and being born in an area with a high incidence of hepatitis B, such as Asia or Africa.  Although most patients with acute hepatitis B will make a complete recovery from the infection, the disease can become chronic and progress to cirrhosis of the liver or even liver cancer.

 Symptoms

Symptoms of hepatitis B infection may occur many weeks after exposure to the virus.  This is known as the incubation period.  Typical symptoms include fatigue, nausea, vomiting, yellowing of the skin and eyes (jaundice), dark urine and light colored stools.  Chronic infection with hepatitis B may be asymptomatic.  Patients who develop end stage liver disease or cirrhosis may suffer complications such as confusion, abdominal swelling, gastrointestinal bleeding and liver cancer.

 Testing

Diagnosis of hepatitis B is suspected when patients have appropriate symptoms and laboratory tests demonstrate abnormal liver enzymes in the blood.  Diagnosis can be confirmed by looking for specific antibodies in the blood, which represent the body’s immune response to the infection.  Sophisticated blood tests can be performed to actually detect and measure the virus in the bloodstream.  A biopsy of the liver may be required to determine the degree of inflammation and scarring present.  Imaging studies such as ultrasound, CAT scan and MRI may be required to look for evidence of cirrhosis and to screen for the development of hepatocellular cancer.

 Treatment

Hepatitis B can be prevented through vaccination.  Patients with acute hepatitis B typically recover spontaneously and require supportive care.  Patients with chronic hepatitis B infection may be candidates for medical therapies to try and eliminate the virus from the body or suppress it to prevent progression to chronic liver disease and liver cancer.  Patients with liver failure due to cirrhosis may ultimately require liver transplantation.

Hepatitis C

Overview

Hepatitis C is an infection of the liver caused by the hepatitis C virus.  Most patients with hepatitis C are asymptomatic and have chronic infection.  The acute infection is often asymptomatic and causes no symptoms.  The virus persists in the liver in about 85% of patients after acute infection.  The disease is transmitted from infected body fluids.  Risk factors include intravenous drug use, tattoos, blood transfusion and rarely sexual exposure.

Symptoms

Most patients with acute hepatitis C have no symptoms or mild symptoms such as fatigue.  Occasionally acute infection can cause yellowing of the skin or eyes, such as jaundice.  Patients with chronic infection are typically asymptomatic until they develop end stage liver disease or cirrhosis.

Testing

Diagnosis of hepatitis C is made in patients with abnormal liver enzymes by detecting an antibody to hepatitis C virus in the blood which is an immune response to the infection.  Sophisticated testing can also be done to determine the quantity of virus in the bloodstream.  A liver biopsy may be necessary to determine the degree of inflammation and/or permanent damage to the liver.

Treatment

Hepatitis C can effectively be treated.  Current regimens include injection with a medication called interferon in combination with oral medications.  Recent studies suggest that in the near future, effective treatment will be available using only oral medications.  Left untreated, hepatitis C can progress to cirrhosis or even hepatocellular carcinoma.  A vaccine to prevent hepatitis C is currently not available.

Liver Cancer

Overview

Hepatocellular carcinoma is the most common type of liver cancer.  It is often associated with underlying viral hepatitis or other forms of chronic liver disease and cirrhosis.  It is a rare tumor in the United States, but is very common in areas of the world where hepatitis B is prevalent.

Symptoms

Hepatocellular carcinoma may present with pain in the right upper abdomen over the liver.  It may be associated with jaundice or yellowing of the skin, fluid accumulation in the abdomen, fatigue, and weight loss.

Testing

Hepatocellular carcinoma is typically diagnosed by an imaging study of the liver, such as ultrasound, CAT scan or MRI.  Blood testing will often reveal elevated liver enzymes and an abnormal level of alpha fetoprotein.  A biopsy of the tumor may be necessary to confirm the diagnosis.

Treatment

Treatment of hepatocellular carcinoma is dependent on the size of the tumor, the number of lesions, evidence of metastatic disease and the underlying age and health of the patient.  Treatment options include surgical resection, techniques to oblate or destroy the tumor, chemotherapy or even liver transplantation.

Primary Biliary Cirrhosis

Overview

Primary biliary cirrhosis is an autoimmune disease of the liver, which results in progressive destruction of the small bile ducts within the liver.  It is most often seen in middle-aged women.  It is a chronic, progressive disease, which eventually leads to cirrhosis and liver failure. It is often associated with other autoimmune disorders, such as thyroiditis.

Symptoms

Patients with PBC may experience itching, yellowing of the eyes and skin, fatigue, and collections of cholesterol in the skin around the eyes, known as xanthelasma.  Ultimately, cirrhosis of the liver will ensue and may result in confusion, fluid retention and gastrointestinal bleeding.

Testing

The diagnosis of PBC is typically made when enzymes in the blood are elevated.  A specific antibody known as AMA or antimitochondrial antibody is elevated in most patients.  The diagnosis is confirmed by performing a liver biopsy.

Treatment

Ursodeoxycholic acid is the most frequently used medication to treat this disease.  It has been shown to improve liver blood tests and to slow the progression of the disease.  It is not curative and patients will ultimately require liver transplantation.  Various medications can be used to treat symptoms, such as itching.

Primary Cholangitis

Overview

Primary sclerosing cholangitis is a disease that causes inflammation and subsequent destruction of the bile ducts, the small tubes that drain bile from the liver.  The condition can affect the bile ducts within the liver and also the ducts that drain the liver and gallbladder into the intestine.  It is a chronic and progressive disease which eventually leads to cirrhosis of the liver.  Patients with sclerosing cholangitis often also have inflammatory bowel disease.

Symptoms

Patients with PSC often present with jaundice or yellowing of the eyes and skin.  The accumulation of bile salts may cause itching.  Ineffective drainage of the liver can result in recurrent episodes of infection called cholangitis.  Eventually, cirrhosis may cause complications such as confusion, abdominal swelling or gastrointestinal bleeding.

Testing

The diagnosis of PSC is often suspected initially when liver enzymes in the blood are elevated.  The diagnosis is confirmed by performing a test to visualize the bile ducts, such as an MRI or ERCP.  A liver biopsy may be performed to assess the degree of damage that has been done to the liver.

Treatment

No specific therapy has been shown to cure or delay the progression of PSC to cirrhosis or liver failure.  Episodes of infection are treated with antibiotics.  Strictures, or narrowing of the bile ducts, may be treated with dilatation or placement of a stent, a plastic tube that is placed in the bile duct to bypass the area of obstruction.  Ultimately, patients with PSC will require liver transplantation.