There are over 100 types of liver disease, which affect around two million people in the UK. The actual figure may be much higher, as many cases of liver disease go undiagnosed.Tests for different types of liver disease
The tests and procedures most commonly used in diagnosing the main liver conditions are listed below:
Autoimmune hepatitis
Test for Autoantibodies such as anti-nuclear antibody and anti-smooth muscle antibody by taking a blood sample.
Haemochromatosis
Testing for HFE Gene analysis for C282Y or H63D mutation by taking a blood sample.
Hepatitis A
Testing for specific Antibodies by taking a blood sample.
Hepatitis B
Testing for specific Antibody, antigen tests/hepatitis B DNA (by taking a blood sample).
Hepatitis C
Testing for specific Antibody/hepatitis C RNA (by taking a blood sample).
Fatty liver disease, non alcohol related fatty liver disease (NAFLD), non alcoholic steatohepatitis (NASH)
Personal history together with testing for liver function (by taking a blood sample) and BMI/ultrasound scan appearance and liver biopsy.
Primary biliary cholangitis (PBC)
Testing for anti-mitochondrial antibody (by taking a blood sample).
Primary sclerosing cholangitis
Liver biopsy and/or bile duct imaging – ERCP
Wilson's disease
Genetic analysis/copper studies (blood and urine samples), slit lamp examination of the eyes.
Liver function tests
What are liver function tests?
Liver blood tests (formerly known as LFTS/Liver function tests) look at how well the liver is functioning and can indicate whether there is any damage or inflammation inside the liver. Until recently, liver blood tests were referred to as liver function tests, or LFTs.
However, as most patients with abnormal liver blood tests actually have normal function of the liver, this term was felt to be unhelpful and often led to unnecessary concern. Therefore the term liver function tests, or LFTs, has been replaced by liver blood tests. This is a very important change, and the medical profession is working hard to ensure the new term is widely accepted and used.
Calling these tests liver blood tests is a more accurate way of describing what the test actually does and uses less frightening language.
What happens when I have a liver blood test?
When you have a liver blood test, a syringe with a fine needle is used to remove a small amount of blood from a vein in your arm.
The sample can be taken by your GP or a nurse at your local clinic, or by hospital staff (a person who is specially trained to take blood is called a phlebotomist). It will then be sent to a laboratory to be tested.
What is a liver blood test looking for?
A liver blood test looks at the chemicals (enzymes), proteins and other substances made by the liver to assess whether levels of any of these are abnormal. The main ones are:
The sample can be taken by your GP or a nurse at your local clinic, or by hospital staff (a person who is specially trained to take blood is called a phlebotomist). It will then be sent to a laboratory to be tested.
What is a liver blood test looking for?
A liver blood test looks at the chemicals (enzymes), proteins and other substances made by the liver to asses swhether levels of any of these are abnormal.
What are the main liver function tests?
Alkaline phosphatase (ALP) and y-Glutamyltransferase (GGT)
These are enzymes found mainly in the bile ducts of the liver. Increases in ALP and another liver enzyme called y-Glutamyltransferase (GGT) can indicate obstructive or cholestatic liver disease, where the flow of bile from the liver is blocked because of an obstruction of the bile duct. GGT levels are also a potential indicator of how much alcohol a patient drinks and can also be higher in those with non-alcohol related fatty liver disease (NAFLD).
Bilirubin
Bilirubin is produced when red blood cells break down, and is the main pigment in bile (a yellow/green substance made by your liver that aids digestion). An increase of bilirubin causes jaundice, characterised by a yellowing of the eyes and skin in liver disease.
Albumin
This is a protein made by the liver that makes up about 60 per cent of total protein in the blood, helping to maintain tissue growth and repair. It stops fluids from leaking out of blood vessels and carries nutrients and hormones around the body. Albumin levels may decrease if the liver is damaged.
The levels of each of these will be given in numbers and values. The laboratory where the blood is being tested provides a ‘normal value’ or ‘reference value’ against which your test results are measured. This is a broad range into which people without liver disease will fall. An abnormal liver blood test result is defined as being below or above the normal range.
Blood clotting tests
The liver produces proteins that help your blood to clot. If your liver isn’t working well, your blood won’t clot as efficiently, so this test is helpful when assessing liver function or whether it is safe for you to have a planned procedure or surgery.
Below are some specific terms you might hear when doctors assess how well your blood clots:
International normalised ratio (INR)
As the chemicals used to perform the PT test may vary between laboratories, the INR is a calculation doctors use to allow for any differences found when results from different laboratories are compared.
Activated partial thromboplastin time ratio (APTR)
APTR is the time taken for thromboplastin to convert into thrombin, an enzyme which causes clotting by turning fibrinogen into fibrin (see below).
Fibrinogen
This is another substance in the blood that helps clotting by producing fibrin strands. Platelets stick to the fibrin strands to form a plug that prevents bleeding. Some medications, such as aspirin, clopidogrel or warfarin, can affect clotting.
Immunology profile tests
Immunology/autoimmune profile tests are tests in which your doctor looks for liver damage caused by your immune system.
They include:
SMA (smooth muscle antibody)
This is a test used to detect autoimmune diseases such as autoimmune hepatitis (AIH), which is inflammation of the liver that occurs when the immune system attacks the liver cells. A liver biopsy is usually necessary to confirm the diagnosis and stage of the disease.
LKM (liver/kidney/microsomal antibody)
This test can be positive in another type of autoimmune hepatitis.
Imaging tests
Imaging tests allow doctors to take detailed images of your internal organs and tissue, and assess the size, shape and surface appearance of your liver. They can also test the stiffness of the liver – healthy liver tissue is soft, so stiffness indicates that damage has occurred.
For further information about these tests please talk to your specialist or your medical team.
Elastography
There is a technique similar to ultrasound, known as elastography, or transient elastography, which doctors can use to measure the stiffness of the liver. Healthy liver tissue is soft, so if stiffness is detected, fibrosis (scar tissue) may be present. The most common name for this kind of test is FibroScan. Tests such as FibroScan can’t diagnose specific liver diseases but they can give doctors an idea of how badly the liver is damaged.
Sheer wave elastography (SWE)
This is a more advanced version of the technique described above, which uses a focused ultrasound wave to give radiologists a clearer picture of how ‘elastic’ (soft) the liver is. The waves travel slowly through healthy liver tissue and faster through scarred areas.
Acoustic radiation force impulse imaging (ARFI)
This is another imaging technique. It works by ‘pushing’ the tissues in the body to assess their stiffness – softer, healthy tissue is more easily pushed than stiffer tissue, which may indicate fibrosis.
CT Scans
This scan is useful for showing several types of tissue very clearly, most commonly the lungs, bones, soft tissues and blood vessels. A CT scan is one of the best tools for studying the chest and abdomen (stomach area), and is particularly useful in detecting excess fat in the liver (fatty liver). Sometimes CT scans are also used to help guide doctors using needles for biopsies.
The CT scanner itself is a large ring-shaped machine into which you will be moved backwards and forwards. This is to allow the scanner to send a number of narrow beams across your body in a circular motion to provide very detailed images of the area under examination. It takes around 10 minutes, unless many pictures are required, which may take 20 to 30 minutes.
MRI (magnetic resonance imaging)
MRI uses a type of tube scanner to provide a more detailed view of your organs than a CT scan. It is a very useful tool for investigating tumours both before and after treatment. A type of MRI scan called Liver MultiScan is sometimes used to accurately measure the amount of fat, fibrosis (scarring) and inflammation present in the liver.
You will be required to remain very still. The scan isn’t at all painful, although some people may find being inside the scanner claustrophobic. It can take up to one hour but the majority of scans will take between 20 and 30 minutes.
MRE (magnetic resonance elastography)
This is an MRI-based advanced technology that uses imaging with soundwaves to create a detailed picture of the body, and is particularly good at showing hardening and stiffness of liver tissue. A small pad is placed on the skin, through which low-frequency vibrations are passed into the liver. A computer measures the speed at which tissues in the liver vibrate – the quicker the vibrations, the more fibrosis is present. MRE can detect fibrosis at an earlier stage than other tests, and give an indication of how severe the fibrosis is.
MRCP (magnetic resonance cholangiopancreatography)
MRCP is a test using specialised magnetic resonance imaging (MRI, above) to provide doctors with a picture of your biliary (bile-carrying)
and pancreatic ducts. In this scan, the fluid in your biliary ducts appears brighter while the surrounding organs and tissues will appear darker.
The procedure can be used to find out whether gallstones are lodged in any of the ducts surrounding your gallbladder. The scan is painless and takes about ten minutes unless combined with a normal MRI scan (an extra 20 to 30 minutes) and is normally performed as an outpatient appointment.
X-rays
An X-ray is a common and painless examination in which invisible radioactive waves are passed through your body to record an image of your internal organs. A special X-ray that studies the veins and arteries that supply blood to the liver is known as hepatic angiography. This X-ray may be needed if your diagnosis is still doubtful after a CT and MRI scan. The procedure uses a catheter (a thin, flexible tube) that is placed into blood vessel though a small cut in your groin. A dye, referred to as a ‘contrast dye’ or ‘contrast medium’, is then injected through the catheter to light up the blood vessels to make them easier to see. A hepatic angiogram is usually done under local anaesthetic and you are also likely to be given sedation. Because of this, you may be asked to stay in hospital overnight (the minimum stay is six hours). The test is usually uncomfortable, rather than painful. You should be able to drive the next day.
Endoscopic Procedures
Endoscopic procedures are a reliable method of investigating the body’s internal organs. An endoscope is a long, flexible fibre optic tube with a tiny camera and a light on the end.
Endoscopic retrograde cholangiopancreatography (ERCP)
ERCP is an endoscopic procedure that helps doctors to see if there are problems with your bile ducts, gallbladder or pancreas. It can show up blockages, whether gallstones are present, narrowing of the bile ducts and tumours. ERCP can also be used in the treatment of gallstones, helping to dislodge, break down and remove them.
The hospital at which you’ll have your ERCP will provide you with guidelines on any preparations you need to make before the procedure, such as how long beforehand you’ll need to stop eating and drinking, and whether it means any possible changes in your medication. At the beginning of the procedure, the doctor will spray the back of your throat with a local anaesthetic to make it feel numb. Sometimes a local anaesthetic lozenge is used, or you will be given a sedative injection through the drip (venflon) in your hand or arm. This will make you drowsy so that it lessens the discomfort of having a tube passed into your gullet. You will be positioned on your side to follow the curvature of your gut. The doctor will ask you to swallow the first section of the endoscope. After this the doctor will push it further down your gullet into your stomach and duodenum. The doctor will look at images on a TV monitor which come from the endoscope’s camera which is filming the procedure.
Air is also passed into the tube into your gut to make it easier to see the lining of the gut. This may make you feel bloated. The endoscope is designed with an attachment down which small instruments and tubes can be passed. This has many uses:
Contrast dye can be placed into the bile and pancreatic ducts. X-ray pictures are taken immediately after the dye has been given to show up narrowings (strictures), gallstones or tumours pressing on the ducts. A small tissue sample (biopsy) from the lining of the gut can be taken to check for abnormal tissue or cells. If the X-rays show a gallstone obstructing the bile duct, the doctor can widen the duct by making a cut to let the stone into the duodenum (first section of the small intestine). This is called a sphincterotomy.
If there is a narrowing in the bile duct, the doctor can place a stent to open it up and keep it from collapsing. The stent can remain in place to help to drain away bile into the duodenum. The endoscope is gently pulled out when the procedure is completed. It takes around 30 minutes to one hour, depending on what is done.
Your aftercare will depend on the findings of the ERCP. You might be booked in for an overnight stay if you have received a stent or had gallstones removed. The hospital will also provide you with information when you are discharged that will help with any problems that might arise after an ERCP procedure.
Liver biopsy
There are many causes of liver disease and it’s sometimes difficult to diagnose a condition based on symptoms and the tests outlined above. Often a liver biopsy is the only way to make a firm diagnosis and identify how advanced the condition is.
A liver biopsy is usually performed in one day and only occasionally requires an overnight stay. Your liver biopsy will be performed by a doctor who may be a gastroenterologist, hepatologist or a radiologist. You will need to give your consent (permission) to the medical staff to carry out the biopsy and a blood sample will be taken to check your blood’s ability to clot.
A local anaesthetic is given to you prior to the liver biopsy procedure. This may be above the liver area on the right side of your abdomen and below the ribs, or more likely between the lower ribs on your right side. In some cases a light sedative can be given if you require it, but discuss this with your doctor.
Sometimes the liver biopsy will be done under ultrasound guidance so that the liver can be seen and the biopsy directed by the imaging. You may already have had an ultrasound performed prior to the biopsy.
When the local anaesthetic has started to work (the area will feel numb), you will be asked to lie on your back or on your side, depending on where the doctors decide to insert the biopsy needle. This is a long thin tube that is inserted through your anaesthetised skin. You may be asked to take a few deep breaths before the needle or biopsy device is inserted and to hold your breath. Once the needle is inserted it is withdrawn quickly to remove a very small sample of liver tissue.
You will then be asked to lie on your right side so that the weight of your body presses on the wound. This is to make sure the wound clots to aid healing. It also means that you will need to remain in bed on your side or on your back for up to six or eight hours so you are advised to go to the toilet before the liver biopsy. There is a very small risk of either internal bleeding or bile leaking from the liver, but this is rare.
You may experience pain or discomfort during or after the liver biopsy. Not all people do, but varying degrees of pain are not uncommon. You should be provided with adequate pain relief after your biopsy, and once you have completed the recovery stage after the liver biopsy you can usually go home.
Your liver biopsy sample is sent to a pathologist (a doctor who identifies diseases by studying cells and tissues) who will examine it under a microscope and produce a report. This may take about two weeks, and you will have an appointment to discuss your results with your specialist who will explain them to you.
Occasionally, if the blood clotting is too prolonged or in the presence of ascites (an accumulation of fluid in the abdomen), it may not be possible to perform a liver biopsy by the conventional route. In these circumstances the liver biopsy may have to be performed via a vein in the neck. This is called a transjugular liver biopsy. This procedure is usually limited to specialist centres and details would be discussed with you by your consultant or their team.
Liver biopsy is considered the best way for diagnosing liver disease, but it’s important to recognise it’s not completely fool-proof.
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