Abnormal Liver Function Tests

Variant: 1 Abnormal liver function tests. Hepatocellular predominance with mild aminotransferase increase. Initial imaging.

Procedure	Appropriateness Category	Relative Radiation Level
US abdomen	Usually Appropriate	O
US duplex Doppler abdomen	Usually Appropriate	O
US shear wave elastography abdomen	May Be Appropriate	O
MR elastography abdomen	May Be Appropriate	O
MRI abdomen without and with IV contrast with MRCP	May Be Appropriate	O
MRI abdomen without IV contrast with MRCP	May Be Appropriate	O
CT abdomen and pelvis without IV contrast	May Be Appropriate	☢☢☢
US abdomen with IV contrast	Usually Not Appropriate	O
CT abdomen and pelvis with IV contrast	Usually Not Appropriate	☢☢☢
CT abdomen and pelvis without and with IV contrast	Usually Not Appropriate	☢☢☢☢

Variant: 2 Abnormal liver function tests. Hepatocellular predominance with moderate or severe aminotransferase increase. Initial imaging.

Procedure	Appropriateness Category	Relative Radiation Level
US abdomen	Usually Appropriate	O
US duplex Doppler abdomen	Usually Appropriate	O
CT abdomen and pelvis with IV contrast	Usually Appropriate	☢☢☢
MRI abdomen without and with IV contrast with MRCP	May Be Appropriate	O
MRI abdomen without IV contrast with MRCP	May Be Appropriate	O
CT abdomen and pelvis without IV contrast	May Be Appropriate	☢☢☢
US abdomen with IV contrast	Usually Not Appropriate	O
US shear wave elastography abdomen	Usually Not Appropriate	O
MR elastography abdomen	Usually Not Appropriate	O
CT abdomen and pelvis without and with IV contrast	Usually Not Appropriate	☢☢☢☢

Variant: 3 Abnormal liver function tests. Cholestatic predominance. Elevated alkaline phosphatase with or without elevated gamma-glutamyl transpeptidase. Initial imaging.

Procedure	Appropriateness Category	Relative Radiation Level
US abdomen	Usually Appropriate	O
MRI abdomen without and with IV contrast with MRCP	Usually Appropriate	O
CT abdomen and pelvis with IV contrast	Usually Appropriate	☢☢☢
US duplex Doppler abdomen	May Be Appropriate	O
MRI abdomen without IV contrast with MRCP	May Be Appropriate	O
CT abdomen and pelvis without IV contrast	May Be Appropriate	☢☢☢
US abdomen with IV contrast	Usually Not Appropriate	O
US shear wave elastography abdomen	Usually Not Appropriate	O
MR elastography abdomen	Usually Not Appropriate	O
CT abdomen and pelvis without and with IV contrast	Usually Not Appropriate	☢☢☢☢

Variant: 4 Abnormal liver functions tests. Hyperbilirubinemia. Acute or subacute cholestasis. Conjugated or unconjugated. Initial imaging.

Procedure	Appropriateness Category	Relative Radiation Level
US abdomen	Usually Appropriate	O
MRI abdomen without and with IV contrast with MRCP	Usually Appropriate	O
MRI abdomen without IV contrast with MRCP	Usually Appropriate	O
CT abdomen and pelvis with IV contrast	Usually Appropriate	☢☢☢
CT abdomen and pelvis without IV contrast	May Be Appropriate	☢☢☢
US abdomen with IV contrast	Usually Not Appropriate	O
US duplex Doppler abdomen	Usually Not Appropriate	O
US shear wave elastography abdomen	Usually Not Appropriate	O
MR elastography abdomen	Usually Not Appropriate	O
CT abdomen and pelvis without and with IV contrast	Usually Not Appropriate	☢☢☢☢

Panel Members

Summary of Literature Review

Introduction/Background

Initial Imaging Definition

Discussion of Procedures by Variant

Variant 1: Abnormal liver function tests. Hepatocellular predominance with mild aminotransferase increase. Initial imaging.

Variant 1: Abnormal liver function tests. Hepatocellular predominance with mild aminotransferase increase. Initial imaging.
A. US Abdomen

Variant 1: Abnormal liver function tests. Hepatocellular predominance with mild aminotransferase increase. Initial imaging.
B. US Abdomen with IV Contrast

Variant 1: Abnormal liver function tests. Hepatocellular predominance with mild aminotransferase increase. Initial imaging.
C. US Duplex Doppler Abdomen

Variant 1: Abnormal liver function tests. Hepatocellular predominance with mild aminotransferase increase. Initial imaging.
D. US Shear Wave Elastography Abdomen

Variant 1: Abnormal liver function tests. Hepatocellular predominance with mild aminotransferase increase. Initial imaging.
E. CT Abdomen and Pelvis Without IV Contrast

Variant 1: Abnormal liver function tests. Hepatocellular predominance with mild aminotransferase increase. Initial imaging.
F. CT Abdomen and Pelvis With IV Contrast

Variant 1: Abnormal liver function tests. Hepatocellular predominance with mild aminotransferase increase. Initial imaging.
G. CT Abdomen and Pelvis Without and With IV Contrast

Variant 1: Abnormal liver function tests. Hepatocellular predominance with mild aminotransferase increase. Initial imaging.
H. MR Elastography Abdomen

Variant 1: Abnormal liver function tests. Hepatocellular predominance with mild aminotransferase increase. Initial imaging.
I. MRI Abdomen Without IV Contrast With MRCP

Variant 1: Abnormal liver function tests. Hepatocellular predominance with mild aminotransferase increase. Initial imaging.
J. MRI Abdomen Without and With IV Contrast With MRCP

Variant 2: Abnormal liver function tests. Hepatocellular predominance with moderate or severe aminotransferase increase. Initial imaging.

Variant 2: Abnormal liver function tests. Hepatocellular predominance with moderate or severe aminotransferase increase. Initial imaging.
A. CT Abdomen and Pelvis Without IV Contrast

Variant 2: Abnormal liver function tests. Hepatocellular predominance with moderate or severe aminotransferase increase. Initial imaging.
B. CT abdomen and pelvis without and with IV contrast

Variant 2: Abnormal liver function tests. Hepatocellular predominance with moderate or severe aminotransferase increase. Initial imaging.
C. CT Abdomen and Pelvis Without and With IV Contrast

Variant 2: Abnormal liver function tests. Hepatocellular predominance with moderate or severe aminotransferase increase. Initial imaging.
D. MR Elastography Abdomen

Variant 2: Abnormal liver function tests. Hepatocellular predominance with moderate or severe aminotransferase increase. Initial imaging.
E. MRI Abdomen with MRCP

Variant 2: Abnormal liver function tests. Hepatocellular predominance with moderate or severe aminotransferase increase. Initial imaging.
F. US Abdomen

Variant 2: Abnormal liver function tests. Hepatocellular predominance with moderate or severe aminotransferase increase. Initial imaging.
G. US Abdomen with IV Contrast

Variant 2: Abnormal liver function tests. Hepatocellular predominance with moderate or severe aminotransferase increase. Initial imaging.
H. US Duplex Doppler Abdomen

Variant 2: Abnormal liver function tests. Hepatocellular predominance with moderate or severe aminotransferase increase. Initial imaging.
I. US Shear Wave Elastography Abdomen

Variant 3: Abnormal liver function tests. Cholestatic predominance. Elevated alkaline phosphatase with or without elevated gamma-glutamyl transpeptidase. Initial imaging.

Variant 3: Abnormal liver function tests. Cholestatic predominance. Elevated alkaline phosphatase with or without elevated gamma-glutamyl transpeptidase. Initial imaging.
A. CT Abdomen and Pelvis With IV Contrast

Variant 3: Abnormal liver function tests. Cholestatic predominance. Elevated alkaline phosphatase with or without elevated gamma-glutamyl transpeptidase. Initial imaging.
G. US Abdomen

Variant 4: Abnormal liver functions tests. Hyperbilirubinemia. Acute or subacute cholestasis. Conjugated or unconjugated. Initial imaging.

Variant 4: Abnormal liver functions tests. Hyperbilirubinemia. Acute or subacute cholestasis. Conjugated or unconjugated. Initial imaging.
A. US Abdomen

Variant 4: Abnormal liver functions tests. Hyperbilirubinemia. Acute or subacute cholestasis. Conjugated or unconjugated. Initial imaging.
B. US Abdomen with IV Contrast

Variant 4: Abnormal liver functions tests. Hyperbilirubinemia. Acute or subacute cholestasis. Conjugated or unconjugated. Initial imaging.
C. US Duplex Doppler Abdomen

Variant 4: Abnormal liver functions tests. Hyperbilirubinemia. Acute or subacute cholestasis. Conjugated or unconjugated. Initial imaging.
D. US Shear Wave Elastography Abdomen

Variant 4: Abnormal liver functions tests. Hyperbilirubinemia. Acute or subacute cholestasis. Conjugated or unconjugated. Initial imaging.
E. CT Abdomen and Pelvis With IV Contrast

Variant 4: Abnormal liver functions tests. Hyperbilirubinemia. Acute or subacute cholestasis. Conjugated or unconjugated. Initial imaging.
F. CT Abdomen and Pelvis Without and With IV Contrast

Variant 4: Abnormal liver functions tests. Hyperbilirubinemia. Acute or subacute cholestasis. Conjugated or unconjugated. Initial imaging.
G. CT Abdomen and Pelvis Without IV Contrast

Variant 4: Abnormal liver functions tests. Hyperbilirubinemia. Acute or subacute cholestasis. Conjugated or unconjugated. Initial imaging.
H. MRI Abdomen with MRCP

Variant 4: Abnormal liver functions tests. Hyperbilirubinemia. Acute or subacute cholestasis. Conjugated or unconjugated. Initial imaging.
I. MR Elastography Abdomen

Summary of Recommendations

Supporting Documents

The evidence table, literature search, and appendix for this topic are available at https://acsearch.acr.org/list. The appendix includes the strength of evidence assessment and the final rating round tabulations for each recommendation.

For additional information on the Appropriateness Criteria methodology and other supporting documents, please go to the ACR website at https://www.acr.org/Clinical-Resources/Clinical-Tools-and-Reference/Appropriateness-Criteria.

Appropriateness Category Names and Definitions

Appropriateness Category Name	Appropriateness Rating	Appropriateness Category Definition
Usually Appropriate	7, 8, or 9	The imaging procedure or treatment is indicated in the specified clinical scenarios at a favorable risk-benefit ratio for patients.
May Be Appropriate	4, 5, or 6	The imaging procedure or treatment may be indicated in the specified clinical scenarios as an alternative to imaging procedures or treatments with a more favorable risk-benefit ratio, or the risk-benefit ratio for patients is equivocal.
May Be Appropriate (Disagreement)	5	The individual ratings are too dispersed from the panel median. The different label provides transparency regarding the panel’s recommendation. “May be appropriate” is the rating category and a rating of 5 is assigned.
Usually Not Appropriate	1, 2, or 3	The imaging procedure or treatment is unlikely to be indicated in the specified clinical scenarios, or the risk-benefit ratio for patients is likely to be unfavorable.

Relative Radiation Level Information

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Disclaimer

The ACR Committee on Appropriateness Criteria and its expert panels have developed criteria for determining appropriate imaging examinations for diagnosis and treatment of specified medical condition(s). These criteria are intended to guide radiologists, radiation oncologists and referring physicians in making decisions regarding radiologic imaging and treatment. Generally, the complexity and severity of a patient’s clinical condition should dictate the selection of appropriate imaging procedures or treatments. Only those examinations generally used for evaluation of the patient’s condition are ranked. Other imaging studies necessary to evaluate other co-existent diseases or other medical consequences of this condition are not considered in this document. The availability of equipment or personnel may influence the selection of appropriate imaging procedures or treatments. Imaging techniques classified as investigational by the FDA have not been considered in developing these criteria; however, study of new equipment and applications should be encouraged. The ultimate decision regarding the appropriateness of any specific radiologic examination or treatment must be made by the referring physician and radiologist in light of all the circumstances presented in an individual examination