Evaluation of Liver Function Test Abnormalities

Last updated: April 6, 2026, 6:50 PM Pacific Time (PDT)

Interactive chalk-talk flowchart for residents and hospital clinicians. Start by confirming the pattern of abnormality, then sort the differential into hepatocellular, cholestatic, isolated bilirubin, and synthetic dysfunction. The assistant can help interpret partial lab data once activated.

All Hepatocellular Cholestatic Bilirubin Synthetic Back to Main Page

Interactive diagnostic assistant

Activate the assistant to re-rank the dominant LFT pattern and likely diagnoses automatically as you enter data.
Core labs
Synthetic and inflammatory clues
History and bedside clues

Dominant lab patterns

Likely diagnoses from entered data

Helpful next steps if still uncertain

This is a simplified teaching assistant for pattern recognition. It is meant for structured reasoning, not for replacing a full liver evaluation.

Flowchart

Pattern First
Define the pattern of LFT abnormality
Hepatocellular pattern: AST and ALT predominate. Cholestatic pattern: ALP and direct bilirubin predominate. Isolated bilirubin abnormality: bilirubin is elevated out of proportion to AST, ALT, and ALP. Synthetic dysfunction: INR rises, albumin falls, or platelets suggest portal hypertension or advanced chronic liver disease.
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Urgent Triage
Identify danger signals
Acute liver failure, ascending cholangitis, severe jaundice, shock liver, and toxin injury should jump ahead of routine outpatient thinking.
Hepatocellular pattern
High AST/ALT
Acute hepatocellular injury
Think viral hepatitis, ischemic injury, toxin injury, autoimmune hepatitis, or severe alcohol-related hepatitis.
Mild to moderate
Chronic hepatocellular disease
Fatty liver disease, chronic viral hepatitis, medication effect, and autoimmune disease are common anchors.
Cholestatic pattern
Obstructive
Extrahepatic obstruction
Think stone disease, malignant obstruction, or stricture when ALP and bilirubin rise with RUQ symptoms.
Intrahepatic
Intrahepatic cholestasis
Medication injury, sepsis, PBC, PSC, infiltrative disease, and pregnancy-related cholestasis live here.
Isolated bilirubin abnormality
Indirect
Unconjugated hyperbilirubinemia
Usually hemolysis, ineffective erythropoiesis, or Gilbert syndrome rather than primary hepatic failure.
Direct
Conjugated hyperbilirubinemia
Think cholestasis, hepatocellular dysfunction, or inherited transport problems.
Synthetic dysfunction
Urgent
Acute or advanced liver failure
High INR, low albumin, encephalopathy, or thrombocytopenia with cirrhotic features should trigger escalation.
Portal clues
Portal hypertension / chronic liver disease
Falling platelets and albumin can be as informative as the aminotransferase level.
Teaching pearl: many LFT abnormalities are mixed. Naming the dominant pattern helps you choose the next imaging, serology, or medication review step.