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Hepatocellular vs cholestatic liver injury
| Dimension | Hepatocellular | Cholestatic |
|---|---|---|
| Dominant enzymes | ALT and AST | ALP with GGT confirming hepatic origin |
| Classic causes | Viral hepatitis, toxins (acetaminophen), ischemia, autoimmune | Obstruction (stones, malignancy), PBC/PSC, drugs |
| The R ratio | R above 5 | R below 2 (2 to 5 is mixed) |
| First test after the pattern | History, viral serologies, acetaminophen level | Ultrasound for duct dilatation |
| Danger sign | Rising INR and encephalopathy: liver failure | Fever with jaundice: cholangitis, an emergency |
Pearls
- Name the pattern first; it chooses the next test.
- AST more than double ALT with modest values suggests alcohol-related injury.
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