Tests and investigations

We look at the haemoglobin level. Haemoglobin is the protein within red blood cells which carries oxygen around the body. When the haemoglobin level is low, we call this anaemia. There are many potential reasons that a person with liver disease may be anaemic such as blood loss and nutritional deficiencies. We also look at the platelet count. Platelets help our blood to clot when we have a cut.

Because of some of the changes which occur in liver disease, the platelets may be low and this may make people more prone to bleeding. We also look at the white blood cell count (the cells which fight off infection). When the body is under stress, and commonly in infection, the white blood cells rise and so an elevated white blood cell count may indicate infection.

There are a several components of LFTs

Bilirubin – This is a yellow pigment which is made when red blood cells are broken down and recycled. Bilirubin is usually removed from the body by passing through the liver. If the liver is not functioning properly or if there is a blockage in the bile ducts, the bilirubin level may be elevated. This can cause the skin and whites of the eyes to turn a yellowish colour

Albumin- This is a protein which is produced by the liver. This can be used as a marker of the function of the liver. When the liver has more significant dysfunction, the albumin level may be low

ALT – This is an enzyme which exists inside liver cells. If the liver cells become damaged in any way, the enzyme may leak out and be detected in the blood. It is a non-specific test, meaning the level may be elevated for a number of different reasons. However, it often indicates inflammation of the liver.

ALP (Alkaline phosphatase) and GGT (Gamma-GT) – Elevation of these tests may indicate a problem within the bile ducts

INR (Or Pro Thrombin Time) – This is a measure of the clotting function of the blood. In general a higher INR level means “thinner blood” which clots less easily. The test is important in liver disease because the liver is responsible for making the proteins which allow the blood to clot. If the liver is not working properly then it will not produce as many of these proteins and the INR level may be raised.

This test includes some of the important salt levels in the blood – sodium and potassium. Particularly in liver disease, patients may be taking one or more types of diuretic (water tablets) which may affect the balance of these salt levels in the blood.

This test also measures the urea and creatinine levels. These substances are filtered by the kidneys and therefore by knowing the level of these substances in the blood, can act as a marker of how well the kidneys are functioning. Monitoring is again of particular importance when using medications which can alter the kidney function (such as water tablets).

When the liver is scarred (cirrhosis) or with certain infections in the liver, people can be at higher risk of developing cancers in the liver. It is for this reason that you may be monitored with blood tests and an ultrasound scan every 6 months to check everything is stable. In some cases, the AFP can act as a marker for the development of liver cancer which is why we monitor it routinely alongside the ultrasound scan.

You may see this term written on your clinic letters. This simply refers to a whole battery of blood tests looking for many different (often less common) causes of liver disease.

It includes viral tests, iron levels, certain enzyme levels in the blood and also different proteins of the immune system (antibodies).

An ultrasound scan is a non invasive type of scan which uses sound waves to make a picture of the structures within the abdomen. It is usually performed when you have been fasted for a few hours, as this makes it easier to look at some structures like the gall bladder.

This will usually take place in the ultrasound/radiology department and performed by an experienced operator. They will ask you to lay on your back but may ask you to alter your position slightly onto your side during the scan. They will apply a gel onto the ultrasound probe and move it around various points on your abdomen. This will be cold, and your will feel some pressure but it shouldn’t be too uncomfortable.

The ultrasound scan is a very useful test and can allow us to look for a number of things including:

• The liver itself. Whether there is any fatty infiltration of the liver or whether it looks to show any scarring
• Other organs such as the spleen, pancreas, kidneys and gall bladder
• Looking at the large and small bile ducts to see whether there is any suggestion that these may be blocked or narrowed
• Looking at some of the blood vessels which flow into the liver such as the portal vein and checking whether there is any evidence of blood clots within this blood vessel
• Looking at whether there is any excess fluid in the abdomen (ascites)

The ultrasound scan may be done as part of an initial diagnostic test. However it may also be repeated for monitoring.

Scarring (cirrhosis) of the liver, as well as infections such as hepatitis B put people at higher risk of developing cancers in the liver (Hepatocellular carcinomas / “HCC”). If people develop cancers in the liver, we want to identify this at a very early stage so that we have more potentially successful treatment options available. This is why we monitor for HCC every 6 months with an ultrasound scan and an “AFP” blood test

The operator performing your test will generate a report after completing the scan. This will be sent to your doctor who will then review it and talk to your about the results.​​​

A fibroscan is another type of non-invasive test which transmits waves through the liver to measure the stiffness of the liver tissue. Certain conditions can cause fat to accumulate within the liver and the liver cells can become inflamed. If this process continues uninterrupted then over time, the liver tissue can become thickened and develop fibrosis. If this continues further then scarring (cirrhosis) may occur. As fibrosis develops within the liver it becomes more “stiff” and the score from the fibroscan will be higher.

The test may be done as an initial diagnostic test but it may also be done again after a period of time to monitor whether there has been any progression or improvement in the degree of fibrosis.

The scan is very quick and usually only lasts around 5 minutes. You will lay on your back and a probe with some cold gel will be placed in a position in line with the liver. This is usually in the right upper part of the abdomen between the ribs. You may feel a slight bit of pressure and may feel a “clicking” sensation, but it should not be painful.

The fibroscan is performed by one of our specialist liver nurses. They may explain the results to you straight away, but they will also be passed on to your doctor who will review them and discuss the results again when you are next seen in the clinic.

A CT scan is a special type of scan which combines x-rays in multiple planes to create a detailed picture of your abdomen and the organs within it. There are a number of reasons why your doctor may request for you to have a CT scan. Sometimes it can give us more detailed pictures and therefore more information than we have been able to obtain from your ultrasound scan alone. As well as assessing the liver and bile ducts it can also give us information about the other organs in the abdomen such as the spleen, pancreas, bowel and blood vessels.

Your doctor will be able to explain to you why you have been asked to attend for a CT scan.

The scan takes place in the radiology department and is usually very quick. The radiographers will help you onto the scanning table and position you correctly. Many CT scans require use of contrast (a dye which is injected to generate more detailed pictures). The radiographer will check any history of allergies with you before the scan. The scanner is a circular/ring like machine which you will pass through. The table will move you whilst you remain laying on your back. The radiographer will give you instructions during the procedure and may ask you to take some deep breaths. The entire procedure should be done within 10 minutes.

A radiologist will look at the scans and generate a report. This will be sent to your doctor who will discuss the findings with you

An MRI scan is a special type of scan which uses magnetic fields to produce detailed pictures. MRI scans are particularly good for looking at the structure of the liver and the bile ducts. A particular type of MRI scan called an “MRCP” is used to give very detailed pictures of the bile ducts to look for any narrowings or obstruction.

MRI scans take a bit longer. This can vary, but usually between 30-60 minutes. It is a very safe procedure and is non-invasive. However, it does involve laying within the MRI machine which looks a bit like a tunnel. Some people may find this claustrophobic. You will have a call bell with you during the procedure which you can press at any time if you feel too uncomfortable.

Because the machine uses strong magnetic fields, it is important that you do not have any metal on or within your body. This requires removing any piercings, glasses, keys from your pocket etc. You will need to answer a questionnaire before the scan which will ask you about any previous operations, prosthesis within the body, artificial heart valves or pacemakers. Sometimes a contrast (special dye which helps generate more detailed images) is used and the radiographer will check any allergies with you beforehand.

After the procedure, a radiologist will look at the pictures and generate a report. This will be sent to your doctor to review and they will then discuss the findings with you.

Because of the availability of such good non-invasive tests and scans, there is not always a need to perform a liver biopsy. Sometimes the history and other tests give us enough information to be confident about the cause of the liver disease.

However, there are still certain circumstances where a liver biopsy is required. This is often when it is unclear about the cause of the liver disease and where taking a sample of the liver to look at under the microscope would give us further diagnostic information which will guide how we treat the liver problem.

A biopsy involved taking a small sample of liver tissue which is then sent away to the pathology laboratory to be looked at under the microscope.

Your doctor will be able to explain to you why they feel you need a liver biopsy.

They will arrange for you to have some blood tests before the procedure to check that the clotting function of your blood is satisfactory. You will usually be advised to stop taking any blood thinning medications for 1 week prior to the procedure. This includes aspirin, clopidogrel, ticagrelor, edoxaban, rivaroxaban, dabigatran, warfarin. However, your doctor will advise you based on your particular circumstances.

The procedure will be performed by an interventional radiologist. You will lay on your back with your right hand above your head. They will use an ultrasound scanning machine to accurately guide where to take the sample from in the liver. They will apply some disinfectant solution on the skin and give some local anaesthetic to make the area numb. They will then ask you to hold your breath whilst a needle is inserted and a very small sample from the liver is obtained to send off for tests.

Complications from liver biopsy are rare. The most common thing that around 30% of people experience is pain, which usually responds to simple pain killers like paracetamol. Bleeding is usually minimal and you will have had your bloods checked before hand to check that the blood clotting is satisfactory. Rarely (Around 1 in 300) may experience more serious bleeding which may require more treatment. About 25% (of the 1 in 300 people who have more serious bleeding) require a blood transfusion.  There is a very small (less than 1 in 1,000) risk of injury to other organs. The risk is minimized due to the fact that it is done under direct guidance with ultrasound scanning.

After the procedure you will be asked to lay on your right side for 30 minutes and then to lie flat for 90 minutes. You can then sit up slightly but remain on your back for another 2 hours. Usually after a period of observation of 6 to 8 hours you will be able to go home the same day but must have someone to collect you and be with you for 24 hours. You must not drive. Occasionally some people may need to stay in hospital overnight.

The biopsy samples will be sent off immediately but they can take several weeks for all of the tests to be completed. Once they are complete your doctor will receive a report which they will discuss the findings and further management with you.

A gastroscopy is a camera test to look down into the food pipe (oesophagus), the stomach and the first part of the small intestine (duodenum). There are a number of reasons why someone may be referred for a gastroscopy, but particularly in the case of liver disease we arrange a gastroscopy to look for enlarged blood vessels in the food pipe/oesophagus (called “varices”).

When the liver becomes scarred, blood cannot flow as easily through the blood vessels in the liver. As a result, a “back pressure” can build up in the blood vessels which surround the oesophagus and stomach which can then expand and enlarge. The main concern is that these enlarged blood vessels can be prone to bleeding. You may be prescribed a medication called carvedilol to help reduce the pressure in these blood vessels to prevent them from bleeding. However, also techniques called “banding” / band ligation may be needed if the varices are large.

A gastroscopy may be arranged as a diagnostic test initially, just to look whether there are any enlarged blood vessels (varices). If varices are seen then your doctor will decide the next course of action. This may involve starting a medication (carvedilol), but if they are large enough they may decide to refer you for a repeat camera test to have the “banding” procedure. This involves a technique where tight bands are placed over the blood vessels to cut off the blood supply. This then causes an ulcer which heals over and eventually causes scarring. The aim is to reduce the risk of the varices bleeding. The “banding” procedure may need to be repeated several times at 4 weekly intervals.

The following patient information leaflets can give you more information about these procedures:

• Oesophageal_Varices_Patient_Information_Leaflet_FINAL.pdf (elht.nhs.uk)
• Having_a_Gastroscopy__Colonoscopy_Patient_Information_Leaflet.pdf (elht.nhs.uk)

An ERCP (endoscopic retrograde cholangiopancreatography) is a special type of camera test which allows the camera to examine the bile ducts. The camera is inserted in through the mouth, down the food pipe (oesophagus), through the stomach and into the first part of the small intestine called the duodenum. It is here that the bile duct drain from the gall bladder into the small intestine.

For more information on the ERCP procedure, this patient information leaflet gives comprehensive information about the procedure:

• ERCP_Patient_Information_Leaflet.pdf (elht.nhs.uk)