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