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Practice Cases in primary care laboratory medicine

Biochemical “liver function tests”

BMJ 2006; 333 doi: (Published 31 August 2006) Cite this as: BMJ 2006;333:481
  1. W Stuart A Smellie, consultant (,
  2. Stephen D Ryder, consultant2
  1. 1 Clinical Laboratory, General Hospital, Bishop Auckland DL14 6AD
  2. 2 Department of Gastroenterology, Queen's Medical Centre, Nottingham NG7 2UH
  1. Correspondence to: WSA Smellie
  • Accepted 5 June 2006

This article considers two common scenarios of “abnormal” liver test results that may be seen in primary care. It looks at the pitfalls in liver testing and summarises guidance, including further investigations that may or may not be warranted

“Abnormal” liver results (bilirubin or enzymes produced by the liver) are a common finding in the investigation of patients presenting with non-acute illness and often raise questions about the need for, and timing of, further investigation. Although the management of overt liver disease will usually include referral to a secondary care specialist, the thresholds for referral and further investigation in clinically silent situations can be unclear.

Case 1

A 27 year old man presented to his general practitioner with a one week history of fever and malaise. On examination he appeared slightly jaundiced and was febrile (38.5°C). He had no evidence of pharyngitis, cervical lymphadenopathy, or organomegaly.

A full blood count was reported as haemoglobin 142 g/l, increased white cell count (10.4x109/l), and a lymphocytosis (5.1x109/l). Routine chemistry had been done at the same time and showed urea, creatinine, and electrolytes within laboratory reference ranges, raised bilirubin (42 µmol/l) with normal aspartate and alanine transaminases and alkaline phosphatase. A heterophilic antibody test for Epstein-Barr virus (monospot) was positive, and the patient was diagnosed as having infectious mononucleosis. Further testing showed that the bilirubin was 95% unconjugated, haptoglobins and lactate dehydrogenase were normal, no reticulocytes were present, and a blood film was normal in appearance with atypical lymphocytes present.

His symptoms were treated and when he was seen two weeks later his fever had resolved, he was clinically improved, and a repeat liver profile showed that his bilirubin had fallen but was still raised (28 µmol/l). After discussion with the local laboratory no further investigations were recommended and a presumptive …

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