A Man With Weight Loss and Abnormal Liver Function Test
A 60-year-old non-insulin dependent diabetic patient presented with a 3 week history of tiredness and weight
loss (3 kg over one month). He also had intermittent watery diarrhoea. His diabetic control was satisfactory
What are the differential diagnoses at this stage?
The marked increase in serum alkaline phosphatase (ALP) is a sensitive indicator of cholestasis, whether
intrahepatic or extrahepatic and of whatever cause. In the absence of jaundice, space-occupying lesions of the liver need to be considered. A similar elevation of gamma-glutamyltransferase (GGT) confirms the elevation of ALP coming from liver pathology.
The differential diagnosis at this stage is:
(a) space-occupying lesions of the liver, such as hepatocellular carcinoma, metastases;
(b) diseases of the biliary tract, such as cholangitis, primary biliary cirrhosis.
What further investigations will you order?
Although the diagnosis of viral hepatitis is unlikely, resolving acute viral hepatitis may give results of this
kind. Viral hepatitis A, B and C serology should be checked. Other useful tests for impaired liver function
include: auto-immune markers such as anti-nuclear factor, anti-smooth muscle antibody, and serum immunoglobulins. With the suspicion of liver cancer, alpha-fetal protein should be checked.
Ultrasonography is non-invasive and should be done in all cases suspected of liver or biliary tract disease. It
will show up focal lesions such as abscess, primary tumour or metastases. Dilated biliary tract, whether it is
the intrahepatic tree or extrahepatic duct, could be demonstrated.
A more definitive visualization of the intrahepatic and extrahepatic bile ducts is made possible by endoscopic retrograde cholangiopancreatography (ERCP).
It may show up multiple strictures and dilatation of biliary tree and intraductal stones in pyogenic cholangitis; focal strictures in cholangiocarcinoma; or the strictures and beading changes in sclerosing cholangitis.
A liver biopsy may show diagnostic features of parenchymal diseases such as primary biliary cirrhosis, or
sclerosing cholangitis.
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