Liver function test interpretation relies on identifying patterns of injury to guide clinical decision-making. The R-score, calculated by the ratio of ALT to alkaline phosphatase, effectively stratifies liver injury into hepatocellular, cholestatic, or mixed categories. Hepatocellular injury requires evaluating for viral hepatitis, drug-induced liver injury, and autoimmune hepatitis, while cholestatic patterns necessitate ruling out obstructive causes via right upper quadrant ultrasound. Chronic, asymptomatic elevations in ALT or alkaline phosphatase often reflect metabolic-associated fatty liver disease, where fibrosis scores like FIB-4 provide prognostic clarity without requiring invasive biopsies. Isolated hyperbilirubinemia frequently points to Gilbert’s syndrome once hemolysis is excluded. During pregnancy, clinicians must distinguish between common liver conditions and pregnancy-specific pathologies like intrahepatic cholestasis, which requires monitoring serum bile salts and potential treatment with ursodiol to improve fetal outcomes.
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