Elevated liver function tests and jaundice

Erhöhte Leberwerte sind ein Häufiger Befund in der Hausärztlichen Praxis und können ganz unterschiedliche Ursachen haben. Um den möglichen Spätfolgen wie Leberzirrhose oder Leberkrebs vorzubeugen, ist es wichtig, dass die Ursache erhöhter Leberwerte Frühzeitig abgeklärt und eine entsprechende Behandlung eingeleitet wird.

Liver and bile duct disorders have unspecific symptoms, which means they are usually identified at a late stage. These symptoms include fatigue, a feeling of pressure in the upper abdomen, loss of appetite, nausea, digestive problems, itching and jaundice. However, elevated liver function readings can often be detected in the blood in the early stages of liver and bile tract disease (Gamma GT, GPT, GOT, possibly also AP and bilirubin). Laboratory tests, ultrasound, endosonography and ERCP (see below) all play a role in diagnosis. The cause of an abnormal liver function test should be identified and treatment started before long-term damage occurs.

Possible causes of elevated liver function  

An abnormal liver function test has many causes. These can be harmless, serious or very serious. Fig. 1 shows the most common causes of liver disease. In their late stages, these symptoms may lead to cirrhosis of the liver (scarring and loss of function) or even liver cell cancer.

 

Fig. 1: causes of liver disease

Clarification of elevated liver function

A targeted review of the patient’s medical history is an important part of a diagnosis. Findings such as jaundice, abdominal pain, fluid in the abdominal cavity and excess weight also provide information about the cause and the severity of the liver damage. The following tests may be necessary:

  • Ultrasound of the liver and analysis of the liver’s elasticity (elastography). Are the bile ducts enlarged? Are there gallbladder stones or bile duct stones? Does the patient have a tumour or metastasis? Does the patient have a fatty liver or cirrhosis of the liver?
  • Endosonography (endoscopic ultrasound), particularly of the pancreas and bile ducts. An endoscopic ultrasound can identify bile duct stones, bile duct tumours and pancreatic cancer. It is the method with the best resolution for the pancreas. If pancreatic tumours are unclear, it can also be used to take a sample.
  • ERCP (endoscopic retrograde cholangiopancreatography). This method images the bile ducts, gallbladder and pancreatic duct using contrast media. Treatment can be performed at the same time (see Fig. 2). Treatments include removing gallstones, sampling tumours in the bile duct and inserting a stent (tube to drain bile) to treat cholestasis and jaundice.
  • Liver biopsy. If the cause of the elevated liver function is still not clear, it is useful to take a liver sample with a needle under local anaesthetic. The cause can be identified microscopically in the liver sample.

Fig. 2: ERCP for pancreatic tumour or gallstone

Fatty liver

Fatty liver disease is the most common chronic liver disease in Europe. About 30% of the population is affected by it, and this number is increasing. Risk factors include excess weight, diabetes mellitus and lipid metabolism disorder. In 20% of cases, the disease progresses from fatty liver inflammation to cirrhosis of the liver and liver cell cancer. This makes identifying at-risk patients very important. Fatty liver can be diagnosed using abdominal ultrasound in more than 90% of cases.

Cholestasis and Jaundice

Bile is produced in the liver and travels through the bile duct/gallbladder into the duodenum, where it aids digestion. Cholestasis can be caused by drugs, hepatitis B, C, D or alcohol within the liver, and by bile duct stones or tumours outside it. Jaundice may develop as a result of the backlog of bile, causing itching and a yellowing of the skin and eyes.

Gallstones

If gallstones are the cause of jaundice, the stones are flushed out of the gallbladder into the bile ducts. Here, they block the flow of bile and cause upper abdominal pain (biliary colic). Occlusion from a stone in the duodenal papilla can cause dangerous pancreatic inflammation and also cholangitis with the risk of blood poisoning. Bile duct stones usually need to be removed via ERCP after division of the papilla. If suspicion of bile duct stones is moderate or low, an endoscopic ultrasound (endosonography) should be used first. After the endoscopic removal of bile duct stones, the gallbladder is surgically removed within six weeks. Stones in the gallbladder do not usually cause any symptoms and do not have to be removed. This applies to 70% of people with stones.

Bile duct or pancreatic cancer

If jaundice occurs without biliary colic and the bile ducts are enlarged, the patient is often diagnosed with narrowing of the bile ducts as a result of bile duct or pancreatic cancer. Ultrasound and endosonography are used to make this diagnosis. ERCP is then carried out immediately, particularly if there are increased signs of inflammation. Cholestasis is relieved using a stent, as it causes dangerous complications (bile duct inflammation and blood poisoning). If the ERCP cannot be carried out for anatomical reasons, the patient must have a PTCD (percutaneous transhepatic cholangiodrainage). The liver is punctured through the skin and the bile flow is restored using a drain. These procedures involve both diagnosis and treatment at the same time. An interdisciplinary tumour board then discusses whether the patient can be operated on and which treatment is best if not.

Article by Prof. Dr. med. Hasan Kulaksiz, specialist in general internal medicine and gastroenterology.