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Dr Allister J Grant

MB ChB(B'ham) PhD FRCP

The Liver  Liver Function Tests  Dr A J Grant Biography  Patient Information  Fibroscan  Lectures  Contact Us  Site Map  Member Login   
Dr A J Grant is a Consultant Hepatologist (Liver Specialist)
at University Hospitals Leicester NHS Trust.
Welcome to my website! I have developed this website to be used as a resource for patients and health professionals alike. I hope that you will find it useful. Feel free to e-mail back your comments about how the site can be improved.
On my website you will find links to various other websites that give information about all aspects of liver disease. In addition you will find links to lectures that I have given.
If you have abnormal liver function tests or a concern about your liver/bile ducts and would like an opinion from me or even just want to be reassured by having a Fibroscan then you will find my details under contact us above.


Liver Disease
Liver disease is an ever growing problem in the UK with 4% of the population estimated to have abnormal liver function tests. The causes for these abnormalities are myriad, and can range from simple problems such as trivial viral illnesses to complex genetic and metabolic problems.
Most liver diseases are painless and have very few symptoms in the early stages. Consequently a large proportion of the patients that I see have abnormal liver function tests that are discovered upon routine testing for other conditions.
The Normal Liver

The normal liver sits under the right lower ribs and it should not be possible to feel it in the upper abdomen (right).

The liver is the largest solid organ in the body and has literally hundreds of functions. It consists of a large right lobe and a smaller left lobe.

The liver cells or hepatocytes (which make up the majority of the bulk of the liver) produce bile which is transported out of the cells into small bile ducts. Bile then flows into ever larger bile ducts and eventually into the gallbladder  where bile is stored (shown left). When food enters the bowel the gallbladder contracts and bile is pushed into the bowel where it breaks down fats so they can be absorbed.

The hepatic portal vein carries 70% of the oxygenated blood into the liver. It is
made up of the confluence of the superior mesenteric vein (which carries the 
nutrients/toxins absorbed from the gut) and the splenic vein (which drains blood 
form the spleen)(see right). The hepatic artery carries the other 30% of the 
oxygenated blood into the liver. Blood enters the liver in a branch of the hepatic
portal vein and a branch of the hepatic artery accompanied by a bile duct (portal 
triad-see below). Blood then flows through the sinusoids (vascular spaces between 
plates of hepatocytes- liver cells) before it enters a central vein (below). These 
central veins then amalgamate to form the hepatic vein (see right ) which carries 
blood out of the liver and into the rest of the body.

The liver has numerous other important functions. It makes and stores sugar (glucose) in the form of glycogen at times of plenty, and releases glucose back into the blood in times of stress or famine when energy is needed.
The liver also makes fats and cholesterol as well as storing vitamins.
The liver also makes a large number of the proteins that the body requires to function normally. It makes various clotting factors to help blood to clot when we cut ourselves. It also makes albumin which is an important protein that carries substances around the body as well as being important in maintaining the pressure and fluid homeostasis in our blood vessels and tissues. A lack of albumin causes fluid to leak out of blood vessels and into the tissues (commonly into the legs-causing oedema) and into the abdominal cavity (causing ascites).
The liver has an important role in detoxifying drugs (including breaking down alcohol), but it is also needed to activate some drugs (so called pro-drugs).
Lastly, but equally importantly, the liver has a whole host of immune functions which keep us healthy and free from disease.

Liver Function Tests (LFT's)


LFT's are a collective term for a number of different liver tests which give us information about the health (or   otherwise) of various parts of the liver.


AST -aspartate aminotransferase

ALT -alanine aminotransferase

ALP-alkaline phosphatase



GGT- gamma glutamyltransferase


Cirrhosis of the Liver                                                                   


What is cirrhosis?


Cirrhosis is the result of chronic longstanding damage to the liver. This damage leads to the development of scar tissue which replaces healthy liver tissue. As a result of the scaring and disruption of the normal structure of the liver, blood can not flow through the liver as it should which leads to problems. Scarring also impairs the liver’s ability to

  • control infections
  • remove bacteria and toxins from the blood
  • process nutrients, hormones, and drugs
  • make proteins that regulate blood clotting
  • produce bile to help absorb fats—including cholesterol—and fat-soluble vitamins    


Instead of being smooth, this image shows a typical liver that 

has developed cirrhosis and has been removed at the time of 

liver transplantation. The liver has numerous large nodules 

(macronodular cirrhosis) and a distorted shape due to the 

constant regeneration of the liver cells.

What causes cirrhosis?


Cirrhosis has various causes. In the UK, heavy alcohol consumption is the commonest cause of cirrhosis. Other common causes are chronic hepatitis C and hepatitis B, some inherited liver diseases and auto-immune liver diseases (where the body produces antibodies which lead to damage of its own liver) . Obesity is becoming a common cause of cirrhosis especially when associated with diabetes, but also as a sole cause or in combination with alcohol, hepatitis C, or both. Many people with cirrhosis have more than one cause of liver damage.

Cirrhosis is not caused by trauma to the liver or other acute, or short-term, causes of damage. Usually years of chronic injury are required to cause cirrhosis.


What are the symptoms of cirrhosis?


In the early stages of the disease (which may last many years) most people with cirrhosis have no symptoms . However, as the disease progresses and gets more advanced, a person may experience the following symptoms:

  • weakness
  • fatigue
  • loss of appetite
  • loss of muscle
  • itching
  • spider-like blood vessels on the skin
  • abdominal bloating when fluid accumulates in the abdomen which may lead to pain
  • confusion, irritability, lack of concentration, sleepiness
  • bleeding from the stomach


What are the complications of cirrhosis? 


As liver function deteriorates, one or more complications may develop. In some people we may only discover they have cirrhosis when they present with one of the following complications:


Oedema and ascites: When liver damage progresses to an advanced stage, fluid collects in the legs, called oedema, and in the abdomen, called ascites. The presence of ascites means the patient may develop bacterial peritonitis, a serious infection arising in this fluid.



This image shows a patient with large ascites and distended veins on the abdomen.


Bruising and bleeding: When the liver slows or stops producing the proteins needed for blood clotting, a person will bruise or bleed easily.


Portal hypertension: Normally, blood from the intestines and spleen is carried to the liver through the portal vein (see above) but in patients with cirrhosis  the normal flow of blood slows down because the blood finds it difficult to flow though the scarred liver. This increases the pressure in the portal vein. This condition is called portal hypertension and leads to the development of ascites, oesophageal varices and splenomegaly (see below)


Oesophageal varices and gastropathy: When portal hypertension occurs, it may cause enlarged blood vessels in the oesophagus (gullet), called varices, or in the stomach, called gastropathy, or both. Enlarged blood vessels are more likely to burst due to thin walls and increased pressure. If they burst, serious bleeding can occur in the oesophagus or upper stomach, requiring immediate medical attention.



The left hand image is of a normal lower oesophagus and on the right is another lower oesophagus with 4 columns of tortuous large varices.


Splenomegaly: When portal hypertension occurs, the spleen frequently enlarges and holds white blood cells and platelets, reducing the numbers of these cells in the blood. A low platelet count may be the first evidence that a person has developed cirrhosis.


Jaundice: Jaundice occurs when the diseased liver does not remove enough bilirubin from the blood, causing yellowing of the skin and whites of the eyes and darkening of the urine. Bilirubin is the pigment that gives bile its reddish-yellow colour. Jaundice does not occur in all liver diseases and many patients with cirrhosis do not have jaundice.


Sensitivity to medications: Cirrhosis slows the liver’s ability to filter medications from the blood. When this occurs, medications act longer than expected and build up in the body. This causes a person to be more sensitive to medications and their side effects.


Hepatic encephalopathy: A failing liver cannot remove toxins from the blood, and they eventually accumulate in the brain. The build-up of toxins in the brain—called hepatic encephalopathy—can decrease mental function and eventually cause coma. Signs of decreased mental function include confusion, personality changes, memory loss, trouble concentrating, and a change in sleep habits. Encephalopathy can occur rapidly in response to infection, bleeding, abnormal levels of blood sodium or potassium or even constipation. If these are treated then the encephalopathy can often be reversed.


Liver cancer: Hepatocellular carcinoma is a type of liver cancer that can occur in people with cirrhosis. Hepatocellular carcinoma has a high mortality rate, but several treatment options are available. Some patients with cirrhosis are screened every 6 months with an ultrasound scan and a special blood test called AFP (alpha-foetoprotein)


Other problems: Cirrhosis can cause immune system dysfunction, leading to the risk of infection. Cirrhosis can also cause kidney and lung failure, known as hepatorenal and hepatopulmonary syndromes


How is cirrhosis diagnosed?


The diagnosis of cirrhosis is usually based on the presence of a risk factor for cirrhosis, such as alcohol use or obesity, and is confirmed by physical examination, blood tests, and scans. The doctor will ask about the person’s medical history and symptoms and perform a physical examination to observe for clinical signs of the disease. For example, on abdominal examination, the liver may feel hard or enlarged with signs of ascites. The doctor will order blood tests that may be helpful in evaluating the liver and increasing the suspicion of cirrhosis.


To view the liver for signs of enlargement, reduced blood flow, or ascites, the doctor may order an ultrasound scan (USS), computerized tomography (CT) scan or magnetic resonance imaging (MRI) scan. If available locally your doctor may be able to perform a Fibroscan to assess your liver for the presence of fibrosis and cirrhosis.


A liver biopsy can confirm the diagnosis of cirrhosis but is not always necessary. A biopsy is usually done if the result might have an impact on treatment. The biopsy is performed with a needle inserted between the ribs or into a vein in the neck. Precautions are taken to minimize discomfort. A tiny sample of liver tissue is examined with a microscope for scarring or other signs of cirrhosis. Sometimes a cause of liver damage other than cirrhosis is found during biopsy.


How is the severity of cirrhosis measured?


There are many different ways of measuring severity of liver cirrhosis. One of the commonest and longest used system is measurement of the Child-Pugh Score. Five variables are considered: presence of ascites, encephalopathy, serum levels of albumin, total bilirubin, and prolongation of the clotting time. Each of these variables is assigned a score between 1 and 3 according to its severity or degree of abnormality. The scoring system was originally used to predict mortality of cirrhotic patients with regard to shunt surgery but later any type of surgery. Nowadays, the Child-Pugh score is used to assess prognosis of cirrhotic patients in general.











Moderate or Severe

Encephalopathy (grade)




Bilirubin (micromole/L)


Bilirubin in Primary Biliary Cirrhosis (micromole/L)













Albumin (g/L)









The sum of the five scores from the above table is used to assign a “Child-Pugh grade” (also known as a Child’s grade) of  A, B or C  to the patient’s clinical condition at that point in time. This grade is used to gauge mortality using the following table:


Child-Pugh grade

Child-Pugh Score


1 Year


5 year


10 year




Indicates a well functioning liver

84 %

44 %

27 %



Indicates significant functional compromise

62 %

20 %

10 %



Indicates decompensation of the liver

42 %

21 %

0 %







There are a number of other scoring systems currently in use for patients with cirrhosis such as the MELD score (Mayo End Stage Liver Disease Score- make sure you use the correct units in this calculator) PELD, MELD Na,etc.


How is cirrhosis treated?


Treatment for cirrhosis depends on the cause of the disease and whether complications are present. The goals of treatment are to slow the progression of scar tissue in the liver and prevent or treat the complications of the disease. Some diseases that cause cirrhosis can be cured and thus stop the cirrhosis progressing. Examples of this would be people who stop drinking, patients with hepatitis C who may be cured of this virus with treatment. Some diseases such as autoimmune liver diseases and hepatitis B can be controlled for many years with medication. However there are some liver diseases that we don’t have any treatment for and these diseases are slowly progressive. Hospitalisation may be necessary for cirrhosis with complications.


When is a liver transplant indicated for cirrhosis?


A liver transplant is considered when complications cannot be controlled by treatment. Liver transplantation is a major operation in which the diseased liver is removed and replaced with a healthy one from an organ donor. A team of health professionals determines the risks and benefits of the procedure for each patient. Survival rates have improved over the past several years because of drugs that suppress the immune system and keep it from attacking and damaging the new liver.

The number of people who need a liver transplant far exceeds the number of available organs. A person needing a transplant must go through a complicated evaluation process before being added to a long transplant waiting list. Generally, organs are given to people with the best chance of living the longest after a transplant. Survival after a transplant requires intensive follow-up and cooperation on the part of the patient and carer.



Alcohol and the Liver


Under construction


If you want information on alcohol, visit NHS Choices or go to NHS Choices via this link-



Units of alcohol calculator