What labs are recommended for a hepatic workup?

Recommended Laboratory Tests for Hepatic Workup

A comprehensive hepatic workup should include bilirubin, albumin, alanine aminotransferase (ALT), alkaline phosphatase (ALP), and γ-glutamyltransferase (GGT), together with a full blood count. 1

Initial Liver Panel Tests

• Basic liver function tests:
  • Alanine aminotransferase (ALT)
  • Aspartate aminotransferase (AST)
  • Alkaline phosphatase (ALP)
  • γ-glutamyltransferase (GGT)
  • Total bilirubin and direct bilirubin
  • Albumin
  • Prothrombin time (PT)/International Normalized Ratio (INR)
• Complete blood count (CBC) if not performed within the previous 12 months 1, 2

Etiological Workup

When abnormal liver tests are identified, a standard liver etiology screen should include:

Serological Testing

• Viral hepatitis markers:
  • Hepatitis B surface antigen (HBsAg)
  • Hepatitis B core antibody (anti-HBc)
  • Hepatitis C antibody (with reflex PCR if positive) 1, 2
• Autoimmune markers:
  • Anti-mitochondrial antibody (AMA)
  • Anti-smooth muscle antibody (SMA)
  • Antinuclear antibody (ANA) 1, 2
• Iron studies:
  • Serum ferritin
  • Transferrin saturation (performed simultaneously) 1
• Immunoglobulins:
  • IgG, IgA, IgM levels 1, 2

Imaging

• Abdominal ultrasound scan to assess for fatty liver, cirrhosis, biliary obstruction, or mass lesions 1, 2

Additional Tests Based on Clinical Context

• For suspected non-alcoholic fatty liver disease (NAFLD):

  • Fibrosis risk assessment using FIB-4 or NAFLD Fibrosis Score 1
  • Fasting glucose and lipid profile 2

• For suspected metabolic disorders:

  • Alpha-1-antitrypsin level
  • Ceruloplasmin (in patients >3 years old) 1

• For suspected drug-induced liver injury:

  • Detailed medication history including prescription and over-the-counter medications 2

Special Considerations for Children

In pediatric patients, the workup should be modified to include:

• Anti-liver kidney microsomal antibody
• Celiac antibodies
• Alpha-1-antitrypsin level
• Ceruloplasmin (for children >3 years) 1

Interpretation of Results

The pattern of liver enzyme abnormalities can help guide diagnosis:

• Hepatocellular pattern: Predominant elevation of AST and ALT (>5x ULN) with minimal ALP elevation
• Cholestatic pattern: Predominant elevation of ALP (>3-5x ULN) with minimal transaminase elevation
• Mixed pattern: Elevation of both transaminases and ALP 3, 4

When to Refer to a Specialist

Consider referral to hepatology for:

• ALT/AST >5× upper limit of normal (ULN)
• Persistent elevation >6 months despite interventions
• Evidence of advanced liver disease on imaging
• Elevated ALT with elevated bilirubin 2

Remember that the extent of liver blood test abnormality is not necessarily a guide to clinical significance. This is determined by the specific analyte which is abnormal and the clinical context 1.