What are the diagnostic tests for a patient with hepatomegaly, periportal edema, and mildly elevated Liver Function Tests (LFTs)?

From the Guidelines

For a patient with hepatomegaly, periportal edema, and mildly elevated Liver Function Tests (LFTs), I recommend an ultrasound (US) abdomen and US duplex Doppler abdomen as the initial imaging tests. These procedures are complementary and provide unique clinical information to effectively manage the patient’s care 1. The patient's presentation with mildly elevated LFTs and hepatomegaly suggests a hepatocellular predominance with mild aminotransferase increase, which aligns with Variant 1 of the ACR Appropriateness Criteria 1.

The diagnostic workup should also include:

• Viral hepatitis serologies (hepatitis A, B, C)
• Autoimmune markers (ANA, anti-smooth muscle antibody, anti-mitochondrial antibody)
• Iron studies (ferritin, transferrin saturation)
• Ceruloplasmin level
• Alpha-1 antitrypsin level
• Complete metabolic panel
• Complete blood count
• Coagulation studies (PT/INR)
• Serum albumin
• Gamma-glutamyl transferase (GGT) if alcohol use is suspected

The ultrasound with Doppler evaluation will assess portal vein flow and rule out thrombosis, while the laboratory tests will help identify the underlying cause of the patient's symptoms, such as viral hepatitis, autoimmune hepatitis, alcoholic liver disease, non-alcoholic fatty liver disease, or early cirrhosis. The pattern of LFT elevation and imaging findings will guide the diagnostic approach and determine the need for additional tests or a liver biopsy if the diagnosis remains unclear. According to the ACR Appropriateness Criteria, US abdomen and US duplex Doppler abdomen are usually appropriate as the initial imaging for patients with abnormal liver function tests with hepatocellular predominance and mild aminotransferase increase 1.

From the Research

Diagnostic Tests for Hepatomegaly, Periportal Edema, and Mildly Elevated LFTs

• Imaging tests:
  • CT or MRI scans to evaluate the liver and surrounding tissues for signs of inflammation, fibrosis, or other abnormalities 2
  • Ultrasound to assess liver size and texture, and to detect any signs of liver damage or disease 3
• Laboratory tests:
  • Liver function tests (LFTs) to assess the levels of liver enzymes, such as ALT and AST, and to evaluate liver function 4, 5
  • Blood tests to check for signs of infection, inflammation, or other underlying conditions that may be contributing to the patient's symptoms 4
• Histological examination:
  • Liver biopsy to examine the liver tissue for signs of inflammation, fibrosis, or other abnormalities, and to determine the underlying cause of the patient's symptoms 2, 6, 3

Differential Diagnosis

• Ipilimumab-associated hepatitis:
  • Characterized by mild hepatomegaly, periportal edema, and mildly elevated LFTs, similar to the patient's symptoms 2
• Glycogenic hepatopathy:
  • Associated with uncontrolled diabetes mellitus, and characterized by hepatomegaly, increased liver enzymes, and accumulation of glycogen within the hepatocytes 3
• Other causes of hepatomegaly and elevated LFTs, such as viral hepatitis, autoimmune hepatitis, or drug-induced liver injury 4, 5, 6