A 29-year-old woman at 35 weeks of her first pregnancy has had nausea, vomiting and upper abdominal pain for 4 days and is now drowsy. Blood pressure is 128/82 mm Hg and urine protein is negative. Results: ALT 310 U/L and AST 285 U/L (reference below 35), total bilirubin 98 µmol/L (5.7 mg/dL), glucose 2.4 mmol/L (43 mg/dL), INR 2.3, fibrinogen 1.1 g/L (reference 2.0-4.0), creatinine 165 µmol/L (1.9 mg/dL), uric acid and ammonia raised, platelets 118 x10^9/L, haptoglobin normal and no schistocytes on the blood film. Hepatitis A, B and E serology is negative. Which diagnosis do these results most suggest?

Intrahepatic cholestasis of pregnancy

A 66-year-old man finished a 10-day course of amoxicillin-clavulanate for pneumonia 3 weeks ago and now has jaundice and itching. Results: ALT 52 U/L (upper limit 40), ALP 910 U/L (upper limit 130), GGT 690 U/L (upper limit 60), total bilirubin 150 µmol/L (8.8 mg/dL) with direct bilirubin 118 µmol/L, albumin 38 g/L and INR 1.1. Ultrasound shows normal bile ducts and viral hepatitis serology is negative. Drug-induced liver injury is classified by R = (ALT ÷ its upper limit) ÷ (ALP ÷ its upper limit): 5 or more is hepatocellular, 2 or less cholestatic, and between 2 and 5 mixed. Which classification and conclusion fit best?

R 0.19, cholestatic: fits the antibiotic

R 0.19, cholestatic: points to a bile duct stone

R 5.4, hepatocellular: fits the antibiotic

R 0.19, cholestatic: the delay rules out the drug

The original MELD score, used to rank patients with end-stage liver disease for transplant, is calculated from:

AST, ALT and the platelet count

Liver function tests and liver disease patterns

27 DOH Abu Dhabi (HAAD) lab licensing practice questions on Liver function tests and liver disease patterns, part of Clinical Chemistry. The first 25 are below; the first 5 with answers and explanations (tap Show answer after you have chosen), the rest in Learn with a free account.

Question 1 · Hard
A 29-year-old woman at 35 weeks of her first pregnancy has had nausea, vomiting and upper abdominal pain for 4 days and is now drowsy. Blood pressure is 128/82 mm Hg and urine protein is negative. Results: ALT 310 U/L and AST 285 U/L (reference below 35), total bilirubin 98 µmol/L (5.7 mg/dL), glucose 2.4 mmol/L (43 mg/dL), INR 2.3, fibrinogen 1.1 g/L (reference 2.0-4.0), creatinine 165 µmol/L (1.9 mg/dL), uric acid and ammonia raised, platelets 118 x10^9/L, haptoglobin normal and no schistocytes on the blood film. Hepatitis A, B and E serology is negative. Which diagnosis do these results most suggest?
1. AHELLP syndrome
2. BIntrahepatic cholestasis of pregnancy
3. CHyperemesis gravidarum
4. DAcute fatty liver of pregnancy
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Answer: D · Acute fatty liver of pregnancy
The key findings show failing liver function, not just liver cell injury: hypoglycemia, a raised INR, a low fibrinogen and a raised ammonia, with jaundice, kidney injury and a high uric acid in the third trimester. This is the pattern of acute fatty liver of pregnancy, in which microvesicular fat disrupts hepatocyte metabolism and protein synthesis. HELLP syndrome needs hemolysis and usually a platelet count below 100 x10^9/L, and synthetic function is largely preserved; here haptoglobin is normal and the film shows no schistocytes. Intrahepatic cholestasis of pregnancy causes itching and raised bile acids with normal synthesis, and hyperemesis gravidarum is a first-trimester disorder. AFLP is an obstetric emergency, so the glucose, INR and fibrinogen should be phoned at once.
- A: HELLP needs hemolysis and usually platelets below 100 x10^9/L, with synthesis largely preserved.
- B: Cholestasis of pregnancy causes itching and high bile acids, not hypoglycemia or coagulopathy.
- C: Hyperemesis occurs in the first trimester and does not cause liver failure.
Question 2 · Hard
A 66-year-old man finished a 10-day course of amoxicillin-clavulanate for pneumonia 3 weeks ago and now has jaundice and itching. Results: ALT 52 U/L (upper limit 40), ALP 910 U/L (upper limit 130), GGT 690 U/L (upper limit 60), total bilirubin 150 µmol/L (8.8 mg/dL) with direct bilirubin 118 µmol/L, albumin 38 g/L and INR 1.1. Ultrasound shows normal bile ducts and viral hepatitis serology is negative. Drug-induced liver injury is classified by R = (ALT ÷ its upper limit) ÷ (ALP ÷ its upper limit): 5 or more is hepatocellular, 2 or less cholestatic, and between 2 and 5 mixed. Which classification and conclusion fit best?
1. AR 0.19, cholestatic: fits the antibiotic
2. BR 0.19, cholestatic: points to a bile duct stone
3. CR 5.4, hepatocellular: fits the antibiotic
4. DR 0.19, cholestatic: the delay rules out the drug
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Answer: A · R 0.19, cholestatic: fits the antibiotic
R = (52 ÷ 40) ÷ (910 ÷ 130) = 1.3 ÷ 7.0 = 0.19, a cholestatic pattern that matches the high GGT and the mainly conjugated bilirubin. Amoxicillin-clavulanate is one of the commonest causes of drug-induced liver injury, and its injury is typically cholestatic or mixed, most often in older men. It often appears days to several weeks after the course has ended, so the delay does not clear the drug. A ratio of 5.4 comes from putting the ALP term on top, the inverted formula. Normal bile ducts make a stone unlikely, and cholestatic drug injury can take months to settle.
- B: The bile ducts are not dilated, so obstruction by a stone is unlikely.
- C: 5.4 comes from inverting the formula; the ALT term goes on top.
- D: This drug's liver injury typically starts days to weeks after the course ends.
Question 3 · Hard
A 52-year-old man with type 2 diabetes treated with metformin and a BMI of 31 kg/m2 is referred with abnormal liver tests. He reports drinking only at weekends. Results: AST 128 U/L and ALT 52 U/L (reference below 40 for both), GGT 410 U/L (reference below 55), ALP 118 U/L (reference 40-130), bilirubin 22 µmol/L (1.3 mg/dL), albumin 39 g/L, platelets 210 x10^9/L, MCV 104 fL (reference 80-100) and CK normal. Carbohydrate-deficient transferrin is 3.4% (reference below 1.7%). Ultrasound shows a fatty liver with no signs of cirrhosis. These results most strongly suggest that the liver injury is driven by:
1. AMetformin liver injury
2. BInsulin resistance and obesity
3. CRegular excess alcohol intake
4. DSkeletal muscle injury
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Answer: C · Regular excess alcohol intake
The AST/ALT ratio is 128 ÷ 52, about 2.5. In fatty liver from insulin resistance (MASLD) without cirrhosis, ALT is usually higher than AST, so a ratio above 2 with a normal platelet count points elsewhere. Alcohol favors AST because it damages mitochondria, releasing mitochondrial AST, and because it depletes pyridoxal phosphate, which lowers ALT activity more than AST. The high GGT, macrocytosis and raised carbohydrate-deficient transferrin all support regular heavy drinking that the history understates. A normal CK excludes muscle as the source of the AST, and metformin very rarely injures the liver.
- A: Metformin is a very rare cause of liver injury and does not raise CDT or MCV.
- B: MASLD without cirrhosis usually gives ALT above AST and does not raise CDT.
- D: CK is normal, so muscle is not the source of the AST.
Question 4 · Medium
The original MELD score, used to rank patients with end-stage liver disease for transplant, is calculated from:
1. ABilirubin, albumin and ALP
2. BBilirubin, INR and creatinine
3. CAST, ALT and the platelet count
4. DAlbumin, INR and ALT
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Answer: B · Bilirubin, INR and creatinine
The original MELD score combines serum bilirubin, INR and creatinine, which reflect excretory, synthetic and kidney function. Higher scores predict higher short-term mortality and are used to prioritize transplant. MELD-Na adds serum sodium, and MELD 3.0 also adds albumin and sex. Because creatinine and INR enter the score, differences between laboratory methods can shift it.
- A: Bilirubin and albumin are in Child-Pugh; ALP is not part of MELD.
- C: AST, ALT and platelets (with age) make up FIB-4, a fibrosis score, not MELD.
- D: Albumin is in the Child-Pugh score and MELD 3.0, but ALT is in neither.
Question 5 · Hard
A 17-year-old girl has acute liver failure with Coombs-negative hemolytic anemia. AST is 290 U/L and ALT 95 U/L (reference < 35 U/L), ALP 30 U/L (reference 45-150 U/L), total bilirubin 410 µmol/L (24 mg/dL) and INR 3.1. Which diagnosis do these results most suggest?
1. AAcute hepatitis A
2. BWilson disease
3. CAutoimmune hepatitis
4. DParacetamol toxicity
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Answer: B · Wilson disease
Acute liver failure from Wilson disease typically shows Coombs-negative hemolysis from copper released by dying hepatocytes, AST higher than ALT, and an unusually low ALP for the very high bilirubin. An ALP (U/L) to total bilirubin (mg/dL) ratio below 4, with an AST/ALT ratio above 2.2, strongly suggests this cause; here they are about 1.3 and 3. Ceruloplasmin can be misleadingly normal in the acute phase, so urine copper, eye examination and genetic testing are also used. Prompt recognition matters because these patients usually need urgent transplantation.
- A: Hepatitis A gives ALT far higher than AST and does not cause hemolysis with a low ALP.
- C: Autoimmune hepatitis does not usually cause Coombs-negative hemolysis or a very low ALP.
- D: Paracetamol toxicity gives aminotransferases in the thousands.
Question 6 · Medium
Which set of results best fits decompensated cirrhosis?
1. AAlbumin low, INR high, polyclonal gamma globulins high
2. BAlbumin normal, INR normal, monoclonal band present
3. CAlbumin low, INR normal, gamma globulins low
4. DAlbumin high, INR normal, gamma globulins low
Answer and explanation in LearnFree account
Question 7 · Hard
A 42-year-old man with alcohol-related hepatitis has PT 24 s (control 12 s) and total bilirubin 205 µmol/L. Maddrey's discriminant function = 4.6 x (patient PT - control PT) + total bilirubin in mg/dL (1 mg/dL = 17.1 µmol/L), and 32 or more indicates severe disease. What is the result?
1. A122; severe alcohol-related hepatitis
2. B24; not severe
3. C260; severe alcohol-related hepatitis
4. D67; severe alcohol-related hepatitis
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Question 8 · Hard
A 40-year-old man has edema and serum albumin 18 g/L (1.8 g/dL) (reference 35-50 g/L). INR is 1.0; bilirubin, ALT and ALP are normal; total cholesterol is 9.8 mmol/L (379 mg/dL). Which test should be done next to find the cause of the low albumin?
1. ASerum protein electrophoresis
2. BSerum ceruloplasmin
3. CUrine protein-to-creatinine ratio
4. DLiver ultrasound with elastography
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Question 9 · Hard
FIB-4 = (age x AST) ÷ (platelets x √ALT), with AST and ALT in U/L and platelets in x10^9/L. A 56-year-old with MASLD has AST 54 U/L, ALT 36 U/L and platelets 140 x10^9/L. Using cut-offs of below 1.30 (low risk) and above 2.67 (high risk of advanced fibrosis), the result is:
1. A3.6: indeterminate risk
2. B1.96: indeterminate risk
3. C0.60: low risk of advanced fibrosis
4. D3.6: high risk of advanced fibrosis
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Question 10 · Medium
A 54-year-old woman has itching and fatigue. ALP is 420 U/L (reference 40-130 U/L), GGT 360 U/L (reference < 40 U/L), ALT 58 U/L (reference < 35 U/L) and bilirubin is normal; ultrasound shows no bile duct dilatation. Which test is most useful next?
1. ASerum ceruloplasmin
2. BIgM antibody to hepatitis A virus
3. CAlpha-fetoprotein
4. DAnti-mitochondrial antibody
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Question 11 · Easy
Serum albumin often stays normal early in acute liver failure. Its half-life in plasma is about:
1. A2 days
2. B4 months
3. C3 weeks
4. D6 hours
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Question 12 · Easy
Which enzyme rises most specifically with hepatocellular injury, because it is found mainly in liver cell cytoplasm?
1. ALactate dehydrogenase (LD)
2. BAlkaline phosphatase (ALP)
3. CAspartate aminotransferase (AST)
4. DAlanine aminotransferase (ALT)
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Question 13 · Hard
A 45-year-old heavy drinker has taken paracetamol for toothache for 4 days. AST is 4,800 U/L and ALT 3,900 U/L (reference < 40 U/L), INR 2.4 and bilirubin 50 µmol/L (2.9 mg/dL); blood pressure has stayed normal. What is the most likely cause?
1. AAlcohol-related hepatitis
2. BPrimary biliary cholangitis
3. CAlcohol-related steatosis
4. DParacetamol toxicity
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Question 14 · Hard
A 50-year-old woman has sudden right upper quadrant pain. Six hours later: ALT 820 U/L, AST 640 U/L (reference < 40 U/L), ALP 150 U/L (reference 40-130 U/L), bilirubin 45 µmol/L (2.6 mg/dL). Two days later ALT is 240 U/L and ALP 380 U/L, and ultrasound shows a dilated common bile duct. These results are best explained by:
1. AAcute viral hepatitis with secondary cholestasis
2. BAcute obstruction by a bile duct stone
3. CIschemic hepatitis after the episode of pain
4. DAlcohol-related hepatitis with fatty infiltration
Answer and explanation in LearnFree account
Question 15 · Hard
An outpatient sample gives AST 96 U/L (reference < 40 U/L), ALT 22 U/L (reference < 40 U/L), LD 610 U/L (reference 125-220 U/L) and potassium 6.4 mmol/L, with a high hemolysis index. CK and the patient's previous liver tests were normal. The most likely explanation is:
1. AAlcohol-related liver disease
2. BIn vitro hemolysis of the sample
3. CAcute myocardial infarction
4. DEarly acute viral hepatitis
Answer and explanation in LearnFree account
Question 16 · Easy
Which enzyme, like GGT, rises with ALP in liver disease but not in bone disease, and so helps confirm a hepatobiliary source of a raised ALP?
1. AAcid phosphatase
2. BLipase
3. CCreatine kinase
4. D5'-nucleotidase
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Question 17 · Medium
A jaundiced patient has an INR of 2.2. Which response to parenteral vitamin K suggests obstructive jaundice rather than hepatocellular failure?
1. AINR rises further over the next day
2. BINR stays the same after 48 hours
3. CINR falls toward normal within 24-48 hours
4. DAlbumin rises within 24-48 hours
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Question 18 · Hard
At 33 weeks of pregnancy, a woman has severe itching of the palms and soles but no rash. ALT is 160 U/L (reference < 35 U/L), and bilirubin, blood pressure and platelet count are normal. Which test best confirms the likely diagnosis?
1. AUrine protein/creatinine ratio
2. BBlood film and haptoglobin
3. CSerum GGT
4. DSerum total bile acids
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Question 19 · Hard
A 30-year-old with acute hepatitis B has these results. Day 1: ALT 3,200 U/L, bilirubin 80 µmol/L (4.7 mg/dL), INR 1.5. Day 5: ALT 850 U/L, bilirubin 290 µmol/L (17.0 mg/dL), INR 3.8, and the patient is confused. How should the fall in ALT be interpreted?
1. ARecovery, as the liver injury is resolving
2. BLaboratory error, since ALT and INR should move together
3. CLoss of hepatocyte mass in worsening liver failure
4. DDevelopment of cholestasis from duct obstruction
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Question 20 · Medium
A 32-year-old man with ulcerative colitis has had ALP and GGT about three times the upper limit for a year, with a mildly raised ALT and a negative anti-mitochondrial antibody. The most likely diagnosis is:
1. AAutoimmune hepatitis type 1
2. BAlcohol-related steatohepatitis
3. CPrimary biliary cholangitis
4. DPrimary sclerosing cholangitis
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Question 21 · Medium
In a patient with chronic hepatitis C or MASLD, a change in the AST/ALT ratio from below 1 to above 1 over several years most suggests:
1. ASuperimposed acute viral hepatitis
2. BResolution of liver inflammation
3. CProgression to advanced fibrosis or cirrhosis
4. DNew obstruction of the bile ducts
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Question 22 · Easy
Which liver enzyme has a mitochondrial isoenzyme that is released in larger amounts after alcohol-related or severe hepatocyte injury?
1. AAlkaline phosphatase
2. BAspartate aminotransferase
3. CGamma-glutamyl transferase
4. DAlanine aminotransferase
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Question 23 · Medium
In cholestasis, serum ALP rises mainly because:
1. AALP normally excreted in the bile is retained in the blood
2. BBile acids induce ALP synthesis in the canalicular membrane
3. CThe kidneys clear less ALP when bilirubin is high
4. DDying hepatocytes leak cytoplasmic ALP into the blood
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Question 24 · Medium
A 48-year-old man with type 2 diabetes and a BMI of 33 kg/m2 drinks no alcohol. ALT is 88 U/L and AST 54 U/L (reference < 40 U/L for both), GGT 70 U/L (reference < 55 U/L), and ALP, bilirubin and albumin are normal. Ultrasound shows a bright, echogenic liver. The most likely diagnosis is:
1. AAcute viral hepatitis
2. BMASLD (steatotic liver disease)
3. CPrimary biliary cholangitis
4. DAlcohol-related hepatitis
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Question 25 · Medium
Refer to the liver test results of four patients shown. In which patient does the raised ALP most likely come from bone?
Figure: MedExams
1. APatient 4
2. BPatient 1
3. CPatient 2
4. DPatient 3
Answer and explanation in LearnFree account

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Study Clinical Chemistry

Liver function tests and liver disease patterns

The original MELD score, used to rank patients with end-stage liver disease for transplant, is calculated from:

A 17-year-old girl has acute liver failure with Coombs-negative hemolytic anemia. AST is 290 U/L and ALT 95 U/L (reference < 35 U/L), ALP 30 U/L (reference 45-150 U/L), total bilirubin 410 µmol/L (24 mg/dL) and INR 3.1. Which diagnosis do these results most suggest?

Which set of results best fits decompensated cirrhosis?

A 42-year-old man with alcohol-related hepatitis has PT 24 s (control 12 s) and total bilirubin 205 µmol/L. Maddrey's discriminant function = 4.6 x (patient PT - control PT) + total bilirubin in mg/dL (1 mg/dL = 17.1 µmol/L), and 32 or more indicates severe disease. What is the result?

A 40-year-old man has edema and serum albumin 18 g/L (1.8 g/dL) (reference 35-50 g/L). INR is 1.0; bilirubin, ALT and ALP are normal; total cholesterol is 9.8 mmol/L (379 mg/dL). Which test should be done next to find the cause of the low albumin?

FIB-4 = (age x AST) ÷ (platelets x √ALT), with AST and ALT in U/L and platelets in x10^9/L. A 56-year-old with MASLD has AST 54 U/L, ALT 36 U/L and platelets 140 x10^9/L. Using cut-offs of below 1.30 (low risk) and above 2.67 (high risk of advanced fibrosis), the result is:

A 54-year-old woman has itching and fatigue. ALP is 420 U/L (reference 40-130 U/L), GGT 360 U/L (reference < 40 U/L), ALT 58 U/L (reference < 35 U/L) and bilirubin is normal; ultrasound shows no bile duct dilatation. Which test is most useful next?

Serum albumin often stays normal early in acute liver failure. Its half-life in plasma is about:

Which enzyme rises most specifically with hepatocellular injury, because it is found mainly in liver cell cytoplasm?

A 45-year-old heavy drinker has taken paracetamol for toothache for 4 days. AST is 4,800 U/L and ALT 3,900 U/L (reference < 40 U/L), INR 2.4 and bilirubin 50 µmol/L (2.9 mg/dL); blood pressure has stayed normal. What is the most likely cause?

An outpatient sample gives AST 96 U/L (reference < 40 U/L), ALT 22 U/L (reference < 40 U/L), LD 610 U/L (reference 125-220 U/L) and potassium 6.4 mmol/L, with a high hemolysis index. CK and the patient's previous liver tests were normal. The most likely explanation is:

Which enzyme, like GGT, rises with ALP in liver disease but not in bone disease, and so helps confirm a hepatobiliary source of a raised ALP?

A jaundiced patient has an INR of 2.2. Which response to parenteral vitamin K suggests obstructive jaundice rather than hepatocellular failure?

At 33 weeks of pregnancy, a woman has severe itching of the palms and soles but no rash. ALT is 160 U/L (reference < 35 U/L), and bilirubin, blood pressure and platelet count are normal. Which test best confirms the likely diagnosis?

A 30-year-old with acute hepatitis B has these results. Day 1: ALT 3,200 U/L, bilirubin 80 µmol/L (4.7 mg/dL), INR 1.5. Day 5: ALT 850 U/L, bilirubin 290 µmol/L (17.0 mg/dL), INR 3.8, and the patient is confused. How should the fall in ALT be interpreted?

A 32-year-old man with ulcerative colitis has had ALP and GGT about three times the upper limit for a year, with a mildly raised ALT and a negative anti-mitochondrial antibody. The most likely diagnosis is:

In a patient with chronic hepatitis C or MASLD, a change in the AST/ALT ratio from below 1 to above 1 over several years most suggests:

Which liver enzyme has a mitochondrial isoenzyme that is released in larger amounts after alcohol-related or severe hepatocyte injury?

In cholestasis, serum ALP rises mainly because:

A 48-year-old man with type 2 diabetes and a BMI of 33 kg/m2 drinks no alcohol. ALT is 88 U/L and AST 54 U/L (reference < 40 U/L for both), GGT 70 U/L (reference < 55 U/L), and ALP, bilirubin and albumin are normal. Ultrasound shows a bright, echogenic liver. The most likely diagnosis is:

Refer to the liver test results of four patients shown. In which patient does the raised ALP most likely come from bone?