Reviews in Internal Medicine ชันปี

้ ที่ 3 หัวข้ อ Approach cirrhosis and complications ในวันอาทิตย์ที่ 26 พ.ย. 2560 เวลา 14:15-15.15 น

Liver function tests interpretation :

RCPT meeting: workshop

Sombat Treeprasertsuk, MD., Ph.D.

Faculty of Medicine, Chulalongkorn University
NOV 23, 2018 (11.30-12.00)
Objectives : to understand

1.Basic concepts of LFT interpretations

2.Common Consultations and LFT
interpretations: cases approach

Nothing to disclose
Summary : problem lists
 Identify major s/s : focus on the most important
problems – eg. Jaundice
 Setting; Onset/Duration : Acute or chronic
?+adjective: characteristic symptoms eg.
progressive .., episodic, chronic recurrent, acute
severe epigastric pain; biliary type...
 Special hosts and possible related causes? :
Compromised , HIV, DM, Elderly.
 Four Benefits Of LFT Interpretation
 Basic interpretation: normal and abnormal
 LFT for Assessing Prognosis, and assessing
Operative Risk
 LFT for guidance the diagnosis of illness
 LFT for guidance of starting and stopping
treatment in specific liver disease
 อาการหรืออาการแสดงไหนมี
Step 2
Step 1 ความจาเพาะสูง และไม่จาเป็ นต ้อง
เป็ นอาการสาคัญ (chief complaint)
ข ้อมูล Database
ให ้พยายามวินจิ ฉั ยแยกโรคจากสงิ่ นั น
้
ระบาด summary
Priority the วิทยา
Acute or
most chronic onset
important Specific
problems – With more hosts? Differential
Chief details; Compromised diagnosis
recurrent, DM, HIV
complaint
progressive,
etc

What,
So what =why,
Problems list and DDx Now what= how

with Priority
Parameters STUDY 1 STUDY 2 STUDY 3 OUR STUDY
Prati D, 2002 Kariv R,2006 Das K, 2010 Treeprasertsuk S,
2011 (N=1879)

ALT ; MALE 30 17 29 Mean = 16.9 + 7.6;

all patients 95th percentile =
33.6

ALT; FEMALE 19 23 M:F = 1:1 Mean =16.6 + 7.9

95th percentile =
32 (M:F = 2:8)

Country/ ITALY, Israel, India, Thailand

Number/ N = 9,331 N = 17,496 N = 1,747 N = 1,879
Age (blood donors) age 15-90 yr age 35.5 + 12.4 yr age 41.7 + 10.1 yr
(check up) (population based) BMI = 24 +
M 19.5 / F19.7 3.9kg/m2
kg/m2

Inclusion criteria Viral serology-neg, Normal glucose, Viral serology- Viral serology-
no sig. alcohol and HbA1c, chol. and TG neg, no sig. neg, no sig.
BMI<25, Normal alcohol and no alcohol
Chol, TG, Glucose fatty liver by
US

Basic interpretation: normal and abnormal

Prati D, et al. Ann Intern Med 2002;137:1-10; Kariv R, et al.. Liver Int 2006; 26:445–450
Das K, et al.Hepatology. 2010;51:1593-602; Dixon JB, et al. Gastro 2001; 121: 91-100
Noninvasive scoring system eg. FIB-4

LFT for Assessing Prognosis

 MELD score for Assessing Prognosis
 Transplant priority status primarily determined by
-1. Model for End-Stage Liver Disease (MELD)
* INR
* Serum bilirubin
* Serum creatinine
 The original mathematical formula for MELD is: MELD
=9.57xLoge(creatinine)+3.78xLoge(total
bilirubin)+11.2xLoge(INR) + 6.43
 CPT-C
MELD = 26

http://www.mayoclinic.org/meld/mayomodel6.html
90 day mortality based on listing MELD score
90
80 71.3% MR
52.6% MR
70
Waitlist mortality %

60
50
40 19.6% MR
1.9% MR
30
20 6% MR

10
0
<9 10-19 20-29 30-39 >40 MELD Score
n=124 n=1800 n=1038 n=295 n=126

Wiesner R, et al.
Model for End-Stage Liver Disease (MELD) Gastroenterology.20
* INR / * Serum bilirubin/ * Serum creatinine 03;124:91-6
CLIF-SOFA score by CANONIC study;
ACLF : 6 major organs dysfunction
LFT for guidance the diagnosis of illness

Moreau R, et al. Gastroenterology 2013;144(7):1426-37.

 Considering specific hosts: Pregnancy,
HIV, Postoperative patients
 Pregnancy Assoc. Acute Liver Disease; PAALD
PAALD Viral hepatitis P-value

T. Bilirubin (mg/dl) 9.9+6.9 11.2+5.5 0.33

AST (U/L) 268+295 828+1045 0.0003

ALT (U/L) 186+138 576+729 <0.0001

Albumin (g/dl) 2.3+0.5 2.9+0.6 <0.0001

PT (sec) 33+22.5 21+7.1 0.0003

a-PTT (sec) 55.2+25.9 45.2+27.1 0.11

Creatinine (mg/dl) 2.4+1.5 1.2+1.3 <0.0001

Devarbhavi H, et al. J Hepatol 2008; 49: 930-5

Coincidental to Underlying Chronic Liver Diseases Unique to Pregnancy
Pregnancy Disease (1-3)

Viral hepatitis (1-3) Chronic hepatitis B or C Hyperemesis gravidarum (1)

Gallstone (1-3) Autoimmune hepatitis Intrahepatic cholestasis of
Drugs (1-3) PSC pregnancy (late 2,3)
Sepsis (1-3) PBC (rare) Preeclampsia (3)

Budd-Chiari* Wilson disease HELLP syndrome (3)

Cirrhosis (uncommon) Acute fatty liver of
pregnancy (3)

*Budd-Chiari syndrome, when associated with pregnancy, usually occurs

in the postpartum period.

Hay JE. Hepatology, Vol. 47, No 3:2008;1067-1076

Approach to patients with Cholestasis

Painless jaundice, diffuse excoriation, stool color

Increased DB Anatomical diagnosis If Intrahepatic. –

(>50%TB) – Exclude • Intrahepatic determine the
Indirect • Extrahepatic(imaging
hyperbilirubinemia; nature
studies are needed)
>85%TB) • Hepatocellular-If
• Extrahepatic causes
• Acquired hepatobiliary imply cholelithiasis, LFT. available and
dis. inflammation, sepsis, xALT/xALP >5 ULN
• Genetic disorders: retained bile salt from or
mutation of bile various causes;
transporter gene eg.
• Cholestatic if
neoplasms, parasites,
PFIC ; progressive pancreatitis xALT/xALP <2 ULN
familial intrahepatic • ERCP/ MRCP may
cholestasis helpful

Reuben A. in Textbook of Clin Gastro Hepato; Hawkey CJ, et al. . (editor) 2012, Chapter 15; p84-92
 Approach to patients with Cholestasis
I. Locate
anatomical
by clinical evaluation
diagnosis

Unconjugated Conjugated hyperbilirubinemia

Clue: - Exclude cirrhosis – signs of CLD
Clue: anemia, rapid
onset, urine color - Location/ character of abdominal pain;
biliary pain with fever and chill?
- Pruritus and Itching; chronicity -favor
Hemolysis intrahepatic and biliary obstruction

Imaging study of hepatobiliary system to

Exclude : Biliary obstruction
II. Determine its - GS/Peri-pancreatic tumors
nature; see Onset/ - Underlying chronic liver dis.
Severity/ setting / - Acalculous cholecystitis
epidemiology

Inpatients setting must R/O

Common problems:
Consider Onset
- Chronic Liver dis: HBV/
HCV, PBC/ PSC./ alcohol
- Acute setting -HBV
/HEV/HAV, Non-
hepatotrophic virus
III. Probable Liver
dis. diagnosis
- Sepsis induced Cholestasis
- Ischemic hepatitis R/O by history taking
- Systemic diseases - eg. Hyperthyroid, - Hepatotoxic agents
Lymphoma - Herbs/dietary-
- Infiltrartive dis: TB/ amyloidosis supplements (HDS)
- Specific hosts: Pregnancy related - Alcoholic hepatitis :
-Multiple blood transfusions – virus, malaria. acute setting
- TPN . Lipid-Long-term use
- Rare: Vanishing bile duct syndrome
1. Hepatocellular uptake – albumin bounded form
2. Intracellular binding – gluthathione S transferases
3. Conjugation process – bilirubin UDP
glucoronosyltransferase (UGT1A1)- Bili. diglucoronide
4. Excretion- transport into portal circulation by MRP-2/3

4
2 DILI
Lymphoma
Hyperthyroid

1
Systemic infection

Harrison's Principles of Internal Medicine 19th Edition, 2015 Chap.58 p281

EASL2016: NFS, FIB-4, FibroTestR , Transient elastography are
acceptable non-invasive
Non-invasive imaging procedures
modalitiesfor identification
for NAFLofseverity
cases at
lower(Hannah
risk ofJradvanced fibrosis
WN, Harrison (high 2016;
SA. Hepatology NPV)doi:10.1002/hep.28699)
Technique Diagnosing Sensitivity Specificity CUT-OFF
% % F3 (kPa)
Vibration controlled >90 >90 8.2-12.5
AUC 0.8-.9
transient elastography
(VCTE) > F3

Point quantification shear 80 85 1.15-1.53

m/sec
wave elastography AUC 0.78-.89
(PSWE): use of acoustic >F2
radiation force impulse
(ARFI)
Shear wave elastography 71-91 71-90 8.3-10.7
(SWE) – several ARFI > F3 AUC 0.83-.92

pulses

Magnetic resonance 74.5 86.9 4.8

elastography (MRE) AUC 0.9
> F3

VCTE: LS >21 kPa = CSPH; values <10-13 kPa: low LR

 ต ัวอย่างการแปลผล
FibroScan-CAP

ตรวจ 10 ครัง้
• Cut-off CAP:
มาหาค่าเฉลีย ่
S0: steatosis <10%:
ค่า >7 KPa มีพังผืด
>S1: >11% to 33%: >215 dB/m),
>S2: >34% to 66%: >252 dB/m
> S3: > 67% to 100% : >296 dB/m

CAP ว ัดปริมาณไขม ันต ับเป็นร้อยละ

- คนปกติมไี ม่เกินร้อยละ 10
คนทีม่ ไี ขม ันเกินร้อยละ 66 - ไม่ด ี
- มีการให้บริการที่ ร.พ.จุฬาลงกรณ์
สาขาโรคระบบทางเดินอาหาร
ั้ 10
ิ ริ ิ ชน
- ตึกภูมส

ปริมาณไขม ันต ับมีรอ

้ ยละ 70 มีพ ังผืดในต ับระด ับ 1
 CLINICAL STAGING OF CIRRHOSIS
ติดตามอาการของผูป ้ ่ วยต ับแข็งทีเ่ วลา 1 ปี พบว่ามีอ ัตราตาย
แตกต่างไปตามระยะของโรคทีแ ่ บ่งได้ 5 ระยะ
(ระยะที่ 5 คือมีภาวะแทรกซอ ้ นเพิม
่ เติมจากระยะที่ 4 เชน ื้ )
่ มีการติดเชอ

TE >10 kPa and

platelet < 150
- EGD for EV

อ ัตราตายแตกต่าง
ไปตามระยะ
ของโรค

D’Amico G, et al. J Hepatology 44 (2006) 217–231

Stage 5 clinical cirrhosis

Arvaniti V, et al. Gastroenterology2010; 139:1246-56.

Objectives : to understand

1.Basic concepts of LFT interpretations

2.Common Consultations and LFT
interpretations: cases approach

Nothing to disclose
 Case Study 1. ผูป
้ ่ วยหญิงไทยคู่ อายุ 65 ปี
ี ค้าขาย ภูมล
 อาชพ ิ าเนา กทม. ประว ัติทไี่ ด้จากผูป ื่ ถือ
้ ่ วยเชอ
ได้มาก
 CC : มีต ัวตาเหลือง 2 เดือนก่อนมาโรงพยาบาล
 2 เดือนก่อนมารพ. มีญาติท ักว่ามีตาเหลืองต ัวเหลือง
 1.5 เดือนก่อนมารพ. มีอาการตาเหลือง-ต ัวเหลืองมากขึน ้ ไม่ม ี
ไข้ ไม่มคี ลืน ่ ไสอ ้ าเจียน ไม่ปวดท้อง รูส ึ อ่อนเพลีย กินได้นอ
้ ก ้ ย
ไม่ค ัน มีนา้ หน ักลดไป 2 กก.ใน 1 เดือน ปัสสาวะสเี ข้ม อุจจาระ
สซี ด
ี ไม่มถี า่ ยเหลว ไม่มถ ี า
่ ยเป็นม ันลอยหรือล้างยาก
 ั
2 สปดาห์ เริม่ มีอาการค ันตามต ัว เกาจนเป็นแผลถลอก ไปรพ.
บางไผ่ ได้ร ับการตรวจเลือด อ ัลตราซาวด์และเอกซเรย์
คอมพิวเตอร์ แล้วไม่พบนิว่ จึงสง ่ มารพ.จุฬาลงกรณ์ ย ังไม่
ทราบการวินจ ิ ฉ ัย
 Physical exam- ผูป ี ค้าขาย
้ ่ วยหญิงไทยคู่ อายุ 65 ปี อาชพ
• Past Hx: ความด ันโลหิตสูง ไขม ันในเลือดสูงกินยามา 5 ปี
 ไม่เคยเจ็ บป่วยต้องเข้ารพ.ไม่เคยมีอาการตาเหลืองต ัวเหลืองมาก่อน ไม่ม ี
ประว ัติร ับเลือด-ไม่เคยสก ั
 Personal Hx: ไม่ดม ื่ สุรา ไม่สบ
ู บุหรี่ มีกน
ิ ปลาร้าอาหารสุกๆดิบๆเป็นประจา
 ไม่มปี ระว ัติ ยาหม้อ ยาลูกกลอน ยาสมุนไพร หรือยาบารุงใดๆ Family Hx: บิดา
เสยี ชวี ต
ิ ด้วยมะเร็งต ับ บิดาดืม
่ สุรามาก
 PE: BW 52 Kg Ht 151 cm,
 VS: BP 135/96 mmHg PR 76 /min BT 37 oc RR 18/min
 GA: A Thai old female, mild pale, marked jaundice, No sign of
Chronic liver disease
 Skin: Marked jaundice, diffuse excoriation (scratch marks)
 LN: cervical and supraclavicular area - negative
 Abdomen: normal contour, no surgical scar, normoactive bowel
sound, not tender, liver 2 FB below RCM- span 12 cm, blunt edge,
firm consistency, smooth surface, no bruit, not tender, Lt lobe no
hypertrophy, Splenic dullness negative, shifting dullness negative
 PR: normal stool colored
 Case 1 : problem lists
 Identify major s/s : focus on the most important prob.
 Setting; Onset/Duration
 Character of hosts

- Chronic progressive painless jaundice in elderly female

patient without sign of chronic liver dis. in 2 mo. (GS --)
- History of raw food / low risk of alc, virus B/C, herbs
- Diffuse skin signs; excoriation,
- History of DLP

DDx* Sequence by
priorities / coverage/ active-inactive problems
Case 1: Lab investigation

Most likely Cholestatic pattern with painless jaundice;

favor extrahepatic cause – periampullary tumors
Consider : xALT/xALP <2 ULN; R ratio = 1.5/3= 0.5
 Etiology of obstructive jaundice
Case 1
Extrahepatic causes
• Congenital: choledochal cyst
• Extrahepatic biliary atresia
• Intraluminal GS
• Biliary stenosis/stricture
(post-operative or inflam.)
• Tumors:
- periampullary cancer
- IPMN
Intrahepatic causes
• Dubin-Johnson synd.
• DILI
• Hepatitis: virus, chemical
• Autoimmune liver:
PBC/AIH
• Infiltrative dis.
• Pregnancy related: AFLP

- Chronic progressive painless jaundice in elderly female

patient without sign of chronic liver dis. in 2 mo. (GS --)
- History of raw food / low risk of alc, virus B/C, herbs
- Diffuse excoriation, DLP
 P-duct
CBD

“double duct sign” refers to the presence of simultaneous dilatation of the CBD and
pancreatic ducts. The most common causes of the double duct sign are pancreatic
cancer (head), CCA, ampullary cancer.
https://radiopaedia.org/cases/double-duct-sign-2
 Case 2: A 31-year-old female
 Known case asymptomatic HIV CD4 564 (30%)
 CC: progressive jaundice for 1 month
 She had no fever or abdominal pain
 She took Andrographis Paniculata capsule
ฟ้ าทะลายโจร for 6 months
 Current medication: Teevir (Tenofovir disoproxil
fumarate 300 mg, efavirenz 600 mg, emtricitabine
200 mg) for 2 year, nadir CD4 224 (16%)
 PH: Good drug compliance, no alcohol drinking /
uncooked food eating / travelling
 Last FU CBC: Hb/Hct 12/36%,
wbc 8300; PMN 86%, PLT 130,000/ mm3
Case 2: A 31-year-old female
Known case asymptomatic HIV CD4 564 (30%)
Physical examination AST> ALT and A/G ratio reversal whereas
 BP 130/70 mmHg, platelet = 130,000
PR 90/min, /mm3afebrile
RR 16 /min,
 Body weight 90 kg, Height 155 cm, BMI 40 kg/m2
 No skin signs of chronic liver disease
 Abdomen: no distension, no mass, liver span 10 cm,
splenic dullness positive
5/12/59 7/12/59 15/12/59 29/12/59

AST 550 393 365 270

ALT 275 266 212 154
ALP 120 133 163 155
TB / DB 6.9/4.0 6.31/4.6 4.4/3.4 2.0/1.31

Alb / Glo 3.1/5.1 3.0/5.4

INR 1.5 1.9 1.7 1.8

Case 2 : problem lists
 Identify major s/s : focus on the most important prob.
 Setting; Onset/Duration
 Character of hosts

- Chronic progressive jaundice in 31-year-old asymptomatic HIV

infected female patient with HIV CD4 564 (30%) with
splenomegaly in 1 month (CLD?) / no biliary pain
- History of Andrographis Paniculata ฟ้าทะลายโจร for 6 months
- Morbid obesity - BMI 40 kg/m2
- ALT 275 (X6.5) , ALP 120 (X1); R – ratio = 6.5 hepatocellular

DDx* Sequence by
priorities / coverage/ active-inactive problems
Approach to patients with Cholestasis

1 mo. progressive jaundice, CLD?, no biliary pain, R ratio 6.5

Increased DB Anatomical diagnosis If Intrahepatic. –

(>50%TB) – Exclude
Indirect
hyperbilirubinemia;
>85%TB)
• Acquired hepatobiliary
dis.
• Genetic disorders:
mutation of bile
transporter gene eg.
PFIC ; progressive
familial intrahepatic
cholestasis
• Intrahepatic
• Extrahepatic(imaging
studies are needed)
• Extrahepatic causes
imply cholelithiasis,
inflammation, sepsis,
retained bile salt from
various causes;
neoplasms, parasites,
pancreatitis
• ERCP/ MRCP may helpful
determine the
nature
• Hepatocellular-If
LFT. available and
xALT/xALP >5 ULN
or
• Cholestatic if
xALT/xALP <2 ULN

Reuben A. in Textbook of Clin Gastro Hepato; Hawkey CJ, et al. . (editor) 2012, Chapter 15; p84-92
 Etiology of obstructive jaundice

Extrahepatic causes Case 2

• Congenital: choledochal cyst Intrahepatic causes
• Extrahepatic biliary atresia • Dubin-Johnson synd.
• Intraluminal GS • DILI
• Biliary stenosis/stricture • Hepatitis: virus, chemical
(post-operative or inflam.) • Autoim liver: PBC/AIH
• Tumors: • Infiltrative dis.
- periampullary cancer • Pregnancy related: AFLP
- IPMN
- Chronic progressive jaundice in 31-year-old asymptomatic HIV
infected female patient with HIV CD4 564 (30%) with
splenomegaly in 1 month (CLD?) / no biliary pain
- History of Andrographis Paniculata ฟ้าทะลายโจร for 6 months
- Morbid obesity - BMI 40 kg/m2
- ALT 275 (X6.5) , ALP 120 (X1); R – ratio = 6.5 hepatocellular
Case 2: A 31-year-old female
Known case asymptomatic HIV CD4 564 (30%)
HBsAg Neg
Anti HBc Neg
Anti HBs Neg
Anti HCV Neg
Anti-HEV IgM Neg
Anti-HEV IgG Neg
IgG (<1700) 3710
AIH: disease activity
ANA 1:320 (Fine speckle/homogenous)
SMA Positive
Sever portal
inflammation,
comprising lymphocytes
Bridging fibrosis

with focal nodular

formation
Cause of death in HIV infected patients

Causes of death in HIV patients

Joshi D, et al. Lancet 2011;377(9772):1198-209.

Common causes of abn. LFT in HIV patients

AIH

Joshi D, et al. Lancet 2011;377(9772):1198-209.

 Autoimmune hepatitis
in HIV infected patients in KCMH
IgG Histological AIH
No Gender Age Infection CD4+ HIV VL level features score Treatment

1 M 47 HIV 924 < 40 2930 Compatible 7 Prednisolone/AZA

2 M 58 HIV/HBV 646 < 40 1800 Compatible 6 Prednisolone/AZA

3 M 27 HIV/HBV 82 < 40 1920 Probable 5 None

4 F 46 HIV 451 < 40 2050 Compatible 7 Prednisolone/AZA

5 F 52 HIV 714 53 3530 Compatible 7 Prednisolone/AZA

AIH overlap
6 F 48 HIV 402 < 40 4000 PBC 7 Prednisolone/AZA/UDCA

7 F 42 HIV 480 < 40 1860 Compatible 6 Prednisolone/AZA

8 F 53 HIV 475 < 40 2300 Compatible 7 Prednisolone/AZA

AIH overlap
9 F 46 HIV 635 < 40 2270 PBC 6 Prednisolone/AZA/UDCA

10 F 44 HIV 772 < 40 4100 Compatible 7 Prednisolone/AZA

Congenit
11 F 15 al HIV 3 436,000 2250 Compatible 7 Sepsis / death

The majority of patients received TDF/FTC/EFV except case #11 received TDF/3TC/DRV/RTV, ANA <1:80, and
SMA negative in case #4, #10
 Simplified diagnostic criteria for the diagnosis of
autoimmune hepatitis (AIH)
Feature/parameter Discriminator Score

ANA or SMA+ ≥1:40 +1

ANA or SMA+ ≥1:80 +2
Or LKM+ ≥1:40
Or SLA+ Any titre
IgG or >Upper limit of normal +1
immunoglobulin level >1.1x upper limit +2
Liver histology Compatible with AIH +1
Typical of AIH +2
Ansence of viral No 0
hepatitis Yes +2
≥6 points: probable AIH; ≥7 points: definite AIH.
*Addition of points achieved for all antibodies (maximum 2 points).
ANA, antinuclear antibody; LKM, liver kidney microsomal antibody; SLA, soluble
live antigen; SMA, smooth muscle antibody.

Hepatology 2008;48:169-76.
 Case study 3: A 55-year-old male with diabetic
and Alc+HBV cirrhosis surveillance for HCC
 PI: Underlying CPT-B cirrhosis present with liver mass by
abdominal CT; 1.7 cm in diameter on right lobe with patent
portal vein. His med; on TDF and HBV DNA-negative
 He still actively drink alcohol 50 gm/day X >10 years
 CT with contrast showed arterial phase enhancement with
rapid portal venous washout, no collateral shunt
 He had previous history of small EV by EGD.
 No history of hepatic encephalopathy or SBP.
 LAB: CBC: Hb 12.6 g/dl, Hct 36% MCV 90, WBC 5,500/mm3,
N 68% L 32%, PLT 130,000 /mm3 , AFP 16 ng/ml
 LFT: TP 7 g/dl, Alb 3.6 g/dl, TB1.0 mg/dl, DB 0.6 mg/dl, ALP
145 U/L, AST 80 U/L, ALT 64 U/L INR of 1.1
 What is the MOST appropriate management?
Case study 3: A 55-year-old male, DM
 A 55-year-old male with diabetic and HBV cirrhosis
surveillance for HCC What is the MOST appropriate
management?
A. Consult for hepatectomy
B. Consult for chemoembolization
C. Treat with oral Sorafenib
D. Observe and serial AFP
E. Liver transplantation

• Underlying CHB +DM+Alcohol drinking

• AST> ALT and low platelet = 130,000 /mm3 favor cirrhosis
• He had previous history of small EV by EGD
• Small liver nodule; typical imaging of HCC
Active alcohol drinking
Case study 3: A 55-year-old male, DM
 A 55-year-old male with diabetic and HBV cirrhosis
surveillance for HCC What is the MOST appropriate
management?
A. Consult for hepatectomy
B. Consult for chemoembolization
C. Treat with oral Sorafenib
D. Consult for Radiofrequency ablation
E. Liver transplantation
 LFT interpretation
: Take home massage

• Assessment of LFT needs clinical evaluation

• Exclude underlying chronic liver diseases
• Identify Anatomical diagnosis then
pathological diagnosis
• Underlying diseases may have a clue BUT
keep it at last
ขอบคุณครับ