Episode two of the Liver Test Interpretation chapter covers what to do when a single value is up with everything else normal, or when the labs aren't the bottleneck and imaging and fibrosis assessment are. Each case forces the same question in a different form: what's the next reflex test, and does it commit you to an invasive workup or excuse you from it? Isolated bilirubin splits on direct versus indirect, isolated alkaline phosphatase splits on GGT, and the fibrosis workup runs FIB-4 before elastography before biopsy. Thresholds, mimic vignettes, and the percutaneous-versus-transjugular decision throughout. Topics covered Isolated hyperbilirubinemia and the direct versus indirect split Separating hemolysis from Gilbert on the indirect side Direct hyperbilirubinemia: Dubin-Johnson and Rotor Isolated alkaline phosphatase and the GGT discriminator Imaging modalities: structure versus fibrosis Transient and MR elastography cutoffs by etiology Serum fibrosis biomarkers and the FIB-4 sequence Liver biopsy indications and technique Percutaneous versus transjugular and the pressure gradient Key decisions Split isolated hyperbilirubinemia at the first line of the panel into indirect versus direct, because the two branches share almost nothing and both are mostly benign. On the indirect side, run a five-value hemolysis screen (haptoglobin, reticulocyte count, smear, LDH, direct Coombs); a clean screen in the right stem is Gilbert, and G6PD hemolysis after trimethoprim-sulfamethoxazole shows bite cells and Heinz bodies. Truly isolated direct hyperbilirubinemia with a normal biliary tree narrows to Dubin-Johnson (black liver, inverted urinary coproporphyrin ratio) or Rotor, both benign, so the answer is reassurance, not biopsy. For isolated alkaline phosphatase, order GGT: elevated GGT confirms a hepatic source, while a normal GGT points to bone and triggers calcium, phosphorus, vitamin D, and a bone fraction or scan. In the fibrosis workup, reach for FIB-4 first (under one point three rules out advanced fibrosis, over two point six seven supports it, with the lower cutoff shifting to two point zero over age sixty-five), then elastography, then biopsy, and anchor elastography cutoffs to etiology. Diagnose hepatocellular carcinoma in a cirrhotic by multiphase MRI or CT showing arterial enhancement, washout, capsule, and threshold growth without biopsy, since biopsy of a definite cancer risks needle-tract seeding. Choose transjugular biopsy over percutaneous for tense ascites, uncorrectable coagulopathy, morbid obesity, or when the hepatic venous pressure gradient is needed, where a gradient of ten or more marks clinically significant portal hypertension and twelve or more correlates with variceal hemorrhage risk. For the full chapter with MCQs, tables, and primary-guideline references, visit www.boardpearls.com. Questions or feedback: [email protected]. (00:00) - The reflex-test framing (00:54) - Isolated hyperbilirubinemia: the first split (01:56) - Hemolysis versus Gilbert on the indirect side (04:27) - Direct hyperbilirubinemia: Dubin-Johnson and Rotor (05:52) - Isolated alkaline phosphatase and GGT (09:00) - Imaging: structure versus fibrosis (10:36) - Elastography and etiology-specific cutoffs (12:35) - Serum biomarkers and the FIB-4 sequence (14:27) - Biopsy indications and the transjugular decision

Ask this episode

“What did the council decide on item 42?” — answered with the speaker and the moment.

Transcript

Related