Chapter 17, Ep 1 of 2: The R Ratio and the Two Workup Tracks

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Recorded16 Jul 2026

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Episode one of the Liver Test Interpretation chapter turns abnormal liver enzymes into a workup by computing the R ratio and committing to a track before ordering another test. The organizing idea: which enzyme dominates and by how many multiples of normal it sits at frames the entire differential, because hepatocellular and cholestatic patterns share almost nothing. The hepatocellular track runs five layers in order (viral, autoimmune, metabolic, ischemic, drug); the cholestatic track branches on a single ultrasound finding, dilated tree or not. Thresholds, magnitude anchors, and reflex panels throughout. Topics covered The R ratio and sorting hepatocellular from cholestatic Hepatocellular injury and magnitude-based differential AST-to-ALT ratio and the redefined normal range Hepatocellular workup: viral, autoimmune, metabolic layers Ischemic (shock liver) and drug-induced injury with Hy's Law Cholestatic workup and the ultrasound branch point Intrahepatic cholestasis: PBC, PSC, and IgG4 disease The mixed pattern and the synthesis Key decisions Compute the R ratio first on any liver vignette: R over five is hepatocellular, R under two is cholestatic, and two to five is mixed, and commit to that track before ordering another test. Acetaminophen and ischemic hepatitis are the two causes that cross an ALT of five thousand; ischemia carries an LDH-to-ALT ratio over one and a half with a hypotensive precedent, while an AST-to-ALT ratio over two with AST under four hundred in a drinker is alcoholic hepatitis until proven otherwise. Use the current normal ALT of under twenty-five for women and under thirty-three for men, because the old range was inflated by undiagnosed fatty liver and hepatitis C. Run the hepatocellular workup in order: viral first (hepatitis B surface antigen and hepatitis C antibody with reflex RNA), autoimmune second (ANA, smooth-muscle, anti-LKM-one, quantitative IgG), metabolic third (transferrin saturation over forty-five percent before HFE testing, ceruloplasmin in anyone under fifty-five). Hy's Law is the drug-injury prognostic anchor: an ALT over three times normal with bilirubin over two without obstruction carries about ten percent mortality even after stopping the drug. In the cholestatic track, get a right-upper-quadrant ultrasound first; a dilated tree goes to MRCP then endoscopic ultrasound for a mass, with ERCP reserved for therapy, while a non-dilated tree triggers anti-mitochondrial antibody and IgM for primary biliary cholangitis. A positive anti-mitochondrial antibody with an alkaline phosphatase over one and a half times normal and AST under five times normal allows a no-biopsy diagnosis of primary biliary cholangitis, and MRCP showing beaded multifocal strictures diagnoses sclerosing cholangitis without ERCP. For the full chapter with MCQs, tables, and primary-guideline references, visit www.boardpearls.com. Questions or feedback: [email protected]. (00:00) - The organizing idea and the R ratio (00:41) - Computing R at the front door (01:18) - Hepatocellular injury and magnitude (03:19) - Redefining the normal range (03:58) - The hepatocellular workup, layered in order (08:39) - Shock liver, drug injury, and Hy's Law (11:11) - The cholestatic workup and the ultrasound branch (12:43) - Intrahepatic cholestasis: PBC, PSC, IgG4 (16:42) - The mixed pattern and the synthesis

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