Extensive, undirected investigation of a patient with abnormal liver tests is not economical and rarely produces a definitive diagnosis. Clinical history and suspicion of the probability of liver disease in a patient is the crucial first step in the evaluation. Physical examination may also provide clues to the diagnosis. The next step in narrowing down the differential diagnosis is to determine the pattern of liver injury, based on the initial liver chemistry tests.

Since tests of liver injury can be categorized as hepatocellular or cholestatic, it is practical to consider liver disease in the same way. Patterns of liver disease can therefore be thought of as either predominantly hepatocellular or biliary (cholestasis). Jaundice can present with either pattern, hepatocellular or cholestatic, and will be covered separately. Ultimately, any type of chronic liver injury may lead to cirrhosis.

In addition to the pattern of liver injury, the onset of disease is also a valuable clue in the evaluation. Certain liver diseases, e.g. hepatitis A, presents as acute illness while others, e.g. hepatitis C, presents as chronic disease. The arbitrary limit that has been set to define an abnormality as chronic is an abnormality that is present for 6 months or more.

In addition to reviewing your liver panel, the following tests should also be ordered: CBC (for platelet count), PT/INR and albumin. These are the most important tests in the evaluation of liver disease as they will reflect the severity of the disease and will determine urgency in referral and evaluation.