Hepatocellular carcinoma laboratory tests: Difference between revisions

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==Overview==
===Overview===
Alpha-fetoprotein (AFP) can be found in the blood of unborn fetuses, but it disappears shortly after birth. When the level of AFP is higher than normal, it suggests that the patient may have hepatocellular carcinoma.


An elevated concentration of serum [[alpha-fetoprotein]] (AFP) may be helpful in the diagnosis of hepatocellular carcinoma.
==Laboratory Findings==
Laboratory finding associated with hepatocellular carcinoma is [[elevated alpha-fetoprotein]].
Alpha-fetoprotein (AFP) can be found in the blood of unborn fetuses, but it disappears shortly after birth. When the level of AFP is higher than normal, it suggests that the patient may have hepatocellular carcinoma.
==Laboratory Findings==
==Laboratory Findings==


* Common abnormalities include:<ref name="pmid22656328">{{cite journal |vauthors=Chalasani N, Younossi Z, Lavine JE, Diehl AM, Brunt EM, Cusi K, Charlton M, Sanyal AJ |title=The diagnosis and management of non-alcoholic fatty liver disease: practice guideline by the American Gastroenterological Association, American Association for the Study of Liver Diseases, and American College of Gastroenterology |journal=Gastroenterology |volume=142 |issue=7 |pages=1592–609 |year=2012 |pmid=22656328 |doi=10.1053/j.gastro.2012.04.001 |url=}}</ref><ref name="pmid22357834">{{cite journal |vauthors=Udell JA, Wang CS, Tinmouth J, FitzGerald JM, Ayas NT, Simel DL, Schulzer M, Mak E, Yoshida EM |title=Does this patient with liver disease have cirrhosis? |journal=JAMA |volume=307 |issue=8 |pages=832–42 |year=2012 |pmid=22357834 |doi=10.1001/jama.2012.186 |url=}}</ref><ref name="pmid27995906">{{cite journal |vauthors=Kwo PY, Cohen SM, Lim JK |title=ACG Clinical Guideline: Evaluation of Abnormal Liver Chemistries |journal=Am. J. Gastroenterol. |volume=112 |issue=1 |pages=18–35 |year=2017 |pmid=27995906 |doi=10.1038/ajg.2016.517 |url=}}</ref><ref name="pmid11853185">{{cite journal |vauthors=Cabrera-Abreu JC, Green A |title=Gamma-glutamyltransferase: value of its measurement in paediatrics |journal=Ann. Clin. Biochem. |volume=39 |issue=Pt 1 |pages=22–5 |year=2002 |pmid=11853185 |doi=10.1258/0004563021901685 |url=}}</ref><ref name="pmid2857631">{{cite journal |vauthors=Moussavian SN, Becker RC, Piepmeyer JL, Mezey E, Bozian RC |title=Serum gamma-glutamyl transpeptidase and chronic alcoholism. Influence of alcohol ingestion and liver disease |journal=Dig. Dis. Sci. |volume=30 |issue=3 |pages=211–4 |year=1985 |pmid=2857631 |doi= |url=}}</ref>  
* Common abnormalities include:<ref name="pmid22656328">{{cite journal |vauthors=Chalasani N, Younossi Z, Lavine JE, Diehl AM, Brunt EM, Cusi K, Charlton M, Sanyal AJ |title=The diagnosis and management of non-alcoholic fatty liver disease: practice guideline by the American Gastroenterological Association, American Association for the Study of Liver Diseases, and American College of Gastroenterology |journal=Gastroenterology |volume=142 |issue=7 |pages=1592–609 |year=2012 |pmid=22656328 |doi=10.1053/j.gastro.2012.04.001 |url=}}</ref><ref name="pmid22357834">{{cite journal |vauthors=Udell JA, Wang CS, Tinmouth J, FitzGerald JM, Ayas NT, Simel DL, Schulzer M, Mak E, Yoshida EM |title=Does this patient with liver disease have cirrhosis? |journal=JAMA |volume=307 |issue=8 |pages=832–42 |year=2012 |pmid=22357834 |doi=10.1001/jama.2012.186 |url=}}</ref><ref name="pmid27995906">{{cite journal |vauthors=Kwo PY, Cohen SM, Lim JK |title=ACG Clinical Guideline: Evaluation of Abnormal Liver Chemistries |journal=Am. J. Gastroenterol. |volume=112 |issue=1 |pages=18–35 |year=2017 |pmid=27995906 |doi=10.1038/ajg.2016.517 |url=}}</ref><ref name="pmid11853185">{{cite journal |vauthors=Cabrera-Abreu JC, Green A |title=Gamma-glutamyltransferase: value of its measurement in paediatrics |journal=Ann. Clin. Biochem. |volume=39 |issue=Pt 1 |pages=22–5 |year=2002 |pmid=11853185 |doi=10.1258/0004563021901685 |url=}}</ref><ref name="pmid2857631">{{cite journal |vauthors=Moussavian SN, Becker RC, Piepmeyer JL, Mezey E, Bozian RC |title=Serum gamma-glutamyl transpeptidase and chronic alcoholism. Influence of alcohol ingestion and liver disease |journal=Dig. Dis. Sci. |volume=30 |issue=3 |pages=211–4 |year=1985 |pmid=2857631 |doi= |url=}}</ref>  
**[[Elevated alpha-fetoprotein]]
** Increased [[Bilirubin|serum bilirubin]] levels<ref name="pmid10498635">{{cite journal |vauthors=Krzeski P, Zych W, Kraszewska E, Milewski B, Butruk E, Habior A |title=Is serum bilirubin concentration the only valid prognostic marker in primary biliary cirrhosis? |journal=Hepatology |volume=30 |issue=4 |pages=865–9 |year=1999 |pmid=10498635 |doi=10.1002/hep.510300415 |url=}}</ref>  
** Increased [[Bilirubin|serum bilirubin]] levels<ref name="pmid10498635">{{cite journal |vauthors=Krzeski P, Zych W, Kraszewska E, Milewski B, Butruk E, Habior A |title=Is serum bilirubin concentration the only valid prognostic marker in primary biliary cirrhosis? |journal=Hepatology |volume=30 |issue=4 |pages=865–9 |year=1999 |pmid=10498635 |doi=10.1002/hep.510300415 |url=}}</ref>  
** Abnormal [[Transaminase|aminotransferase]] levels <ref name="pmid10781624">{{cite journal |vauthors=Pratt DS, Kaplan MM |title=Evaluation of abnormal liver-enzyme results in asymptomatic patients |journal=N. Engl. J. Med. |volume=342 |issue=17 |pages=1266–71 |year=2000 |pmid=10781624 |doi=10.1056/NEJM200004273421707 |url=}}</ref><ref name="pmid27995906" /><ref name="pmid20060831">{{cite journal |vauthors=Ruhl CE, Everhart JE |title=Trunk fat is associated with increased serum levels of alanine aminotransferase in the United States |journal=Gastroenterology |volume=138 |issue=4 |pages=1346–56, 1356.e1–3 |year=2010 |pmid=20060831 |pmc=2847039 |doi=10.1053/j.gastro.2009.12.053 |url=}}</ref><ref name="pmid12093239">{{cite journal |vauthors=Prati D, Taioli E, Zanella A, Della Torre E, Butelli S, Del Vecchio E, Vianello L, Zanuso F, Mozzi F, Milani S, Conte D, Colombo M, Sirchia G |title=Updated definitions of healthy ranges for serum alanine aminotransferase levels |journal=Ann. Intern. Med. |volume=137 |issue=1 |pages=1–10 |year=2002 |pmid=12093239 |doi= |url=}}</ref><ref name="pmid9581673">{{cite journal |vauthors=Piton A, Poynard T, Imbert-Bismut F, Khalil L, Delattre J, Pelissier E, Sansonetti N, Opolon P |title=Factors associated with serum alanine transaminase activity in healthy subjects: consequences for the definition of normal values, for selection of blood donors, and for patients with chronic hepatitis C. MULTIVIRC Group |journal=Hepatology |volume=27 |issue=5 |pages=1213–9 |year=1998 |pmid=9581673 |doi=10.1002/hep.510270505 |url=}}</ref><ref name="pmid12093245">{{cite journal |vauthors=Kaplan MM |title=Alanine aminotransferase levels: what's normal? |journal=Ann. Intern. Med. |volume=137 |issue=1 |pages=49–51 |year=2002 |pmid=12093245 |doi= |url=}}</ref><ref name="pmid15983331">{{cite journal |vauthors=Nannipieri M, Gonzales C, Baldi S, Posadas R, Williams K, Haffner SM, Stern MP, Ferrannini E |title=Liver enzymes, the metabolic syndrome, and incident diabetes: the Mexico City diabetes study |journal=Diabetes Care |volume=28 |issue=7 |pages=1757–62 |year=2005 |pmid=15983331 |doi= |url=}}</ref><ref name="pmid22764020">{{cite journal |vauthors=Liangpunsakul S, Chalasani N |title=What should we recommend to our patients with NAFLD regarding alcohol use? |journal=Am. J. Gastroenterol. |volume=107 |issue=7 |pages=976–8 |year=2012 |pmid=22764020 |pmc=3766378 |doi=10.1038/ajg.2012.20 |url=}}</ref><ref name="pmid520102">{{cite journal |vauthors=Cohen JA, Kaplan MM |title=The SGOT/SGPT ratio--an indicator of alcoholic liver disease |journal=Dig. Dis. Sci. |volume=24 |issue=11 |pages=835–8 |year=1979 |pmid=520102 |doi= |url=}}</ref><ref name="pmid18328931">{{cite journal |vauthors=Schuppan D, Afdhal NH |title=Liver cirrhosis |journal=Lancet |volume=371 |issue=9615 |pages=838–51 |year=2008 |pmid=18328931 |pmc=2271178 |doi=10.1016/S0140-6736(08)60383-9 |url=}}</ref><ref name="pmid19501929">{{cite journal |vauthors= |title=EASL Clinical Practice Guidelines: management of cholestatic liver diseases |journal=J. Hepatol. |volume=51 |issue=2 |pages=237–67 |year=2009 |pmid=19501929 |doi=10.1016/j.jhep.2009.04.009 |url=}}</ref>  
** Abnormal [[Transaminase|aminotransferase]] levels <ref name="pmid10781624">{{cite journal |vauthors=Pratt DS, Kaplan MM |title=Evaluation of abnormal liver-enzyme results in asymptomatic patients |journal=N. Engl. J. Med. |volume=342 |issue=17 |pages=1266–71 |year=2000 |pmid=10781624 |doi=10.1056/NEJM200004273421707 |url=}}</ref><ref name="pmid27995906" /><ref name="pmid20060831">{{cite journal |vauthors=Ruhl CE, Everhart JE |title=Trunk fat is associated with increased serum levels of alanine aminotransferase in the United States |journal=Gastroenterology |volume=138 |issue=4 |pages=1346–56, 1356.e1–3 |year=2010 |pmid=20060831 |pmc=2847039 |doi=10.1053/j.gastro.2009.12.053 |url=}}</ref><ref name="pmid12093239">{{cite journal |vauthors=Prati D, Taioli E, Zanella A, Della Torre E, Butelli S, Del Vecchio E, Vianello L, Zanuso F, Mozzi F, Milani S, Conte D, Colombo M, Sirchia G |title=Updated definitions of healthy ranges for serum alanine aminotransferase levels |journal=Ann. Intern. Med. |volume=137 |issue=1 |pages=1–10 |year=2002 |pmid=12093239 |doi= |url=}}</ref><ref name="pmid9581673">{{cite journal |vauthors=Piton A, Poynard T, Imbert-Bismut F, Khalil L, Delattre J, Pelissier E, Sansonetti N, Opolon P |title=Factors associated with serum alanine transaminase activity in healthy subjects: consequences for the definition of normal values, for selection of blood donors, and for patients with chronic hepatitis C. MULTIVIRC Group |journal=Hepatology |volume=27 |issue=5 |pages=1213–9 |year=1998 |pmid=9581673 |doi=10.1002/hep.510270505 |url=}}</ref><ref name="pmid12093245">{{cite journal |vauthors=Kaplan MM |title=Alanine aminotransferase levels: what's normal? |journal=Ann. Intern. Med. |volume=137 |issue=1 |pages=49–51 |year=2002 |pmid=12093245 |doi= |url=}}</ref><ref name="pmid15983331">{{cite journal |vauthors=Nannipieri M, Gonzales C, Baldi S, Posadas R, Williams K, Haffner SM, Stern MP, Ferrannini E |title=Liver enzymes, the metabolic syndrome, and incident diabetes: the Mexico City diabetes study |journal=Diabetes Care |volume=28 |issue=7 |pages=1757–62 |year=2005 |pmid=15983331 |doi= |url=}}</ref><ref name="pmid22764020">{{cite journal |vauthors=Liangpunsakul S, Chalasani N |title=What should we recommend to our patients with NAFLD regarding alcohol use? |journal=Am. J. Gastroenterol. |volume=107 |issue=7 |pages=976–8 |year=2012 |pmid=22764020 |pmc=3766378 |doi=10.1038/ajg.2012.20 |url=}}</ref><ref name="pmid520102">{{cite journal |vauthors=Cohen JA, Kaplan MM |title=The SGOT/SGPT ratio--an indicator of alcoholic liver disease |journal=Dig. Dis. Sci. |volume=24 |issue=11 |pages=835–8 |year=1979 |pmid=520102 |doi= |url=}}</ref><ref name="pmid18328931">{{cite journal |vauthors=Schuppan D, Afdhal NH |title=Liver cirrhosis |journal=Lancet |volume=371 |issue=9615 |pages=838–51 |year=2008 |pmid=18328931 |pmc=2271178 |doi=10.1016/S0140-6736(08)60383-9 |url=}}</ref><ref name="pmid19501929">{{cite journal |vauthors= |title=EASL Clinical Practice Guidelines: management of cholestatic liver diseases |journal=J. Hepatol. |volume=51 |issue=2 |pages=237–67 |year=2009 |pmid=19501929 |doi=10.1016/j.jhep.2009.04.009 |url=}}</ref>  

Revision as of 15:15, 8 January 2018

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Associate Editor(s)-in-Chief: Dildar Hussain, MBBS [2]

Overview

Alpha-fetoprotein (AFP) can be found in the blood of unborn fetuses, but it disappears shortly after birth. When the level of AFP is higher than normal, it suggests that the patient may have hepatocellular carcinoma.

Laboratory Findings

Liver function tests:

Hematologic abnormalities:  [32]

FibroTest

Other laboratory studies performed in newly diagnosed hepatocellular carcinoma may include:

References

  1. Chalasani N, Younossi Z, Lavine JE, Diehl AM, Brunt EM, Cusi K, Charlton M, Sanyal AJ (2012). "The diagnosis and management of non-alcoholic fatty liver disease: practice guideline by the American Gastroenterological Association, American Association for the Study of Liver Diseases, and American College of Gastroenterology". Gastroenterology. 142 (7): 1592–609. doi:10.1053/j.gastro.2012.04.001. PMID 22656328.
  2. Udell JA, Wang CS, Tinmouth J, FitzGerald JM, Ayas NT, Simel DL, Schulzer M, Mak E, Yoshida EM (2012). "Does this patient with liver disease have cirrhosis?". JAMA. 307 (8): 832–42. doi:10.1001/jama.2012.186. PMID 22357834.
  3. 3.0 3.1 Kwo PY, Cohen SM, Lim JK (2017). "ACG Clinical Guideline: Evaluation of Abnormal Liver Chemistries". Am. J. Gastroenterol. 112 (1): 18–35. doi:10.1038/ajg.2016.517. PMID 27995906.
  4. Cabrera-Abreu JC, Green A (2002). "Gamma-glutamyltransferase: value of its measurement in paediatrics". Ann. Clin. Biochem. 39 (Pt 1): 22–5. doi:10.1258/0004563021901685. PMID 11853185.
  5. Moussavian SN, Becker RC, Piepmeyer JL, Mezey E, Bozian RC (1985). "Serum gamma-glutamyl transpeptidase and chronic alcoholism. Influence of alcohol ingestion and liver disease". Dig. Dis. Sci. 30 (3): 211–4. PMID 2857631.
  6. Krzeski P, Zych W, Kraszewska E, Milewski B, Butruk E, Habior A (1999). "Is serum bilirubin concentration the only valid prognostic marker in primary biliary cirrhosis?". Hepatology. 30 (4): 865–9. doi:10.1002/hep.510300415. PMID 10498635.
  7. Pratt DS, Kaplan MM (2000). "Evaluation of abnormal liver-enzyme results in asymptomatic patients". N. Engl. J. Med. 342 (17): 1266–71. doi:10.1056/NEJM200004273421707. PMID 10781624.
  8. Ruhl CE, Everhart JE (2010). "Trunk fat is associated with increased serum levels of alanine aminotransferase in the United States". Gastroenterology. 138 (4): 1346–56, 1356.e1–3. doi:10.1053/j.gastro.2009.12.053. PMC 2847039. PMID 20060831.
  9. Prati D, Taioli E, Zanella A, Della Torre E, Butelli S, Del Vecchio E, Vianello L, Zanuso F, Mozzi F, Milani S, Conte D, Colombo M, Sirchia G (2002). "Updated definitions of healthy ranges for serum alanine aminotransferase levels". Ann. Intern. Med. 137 (1): 1–10. PMID 12093239.
  10. Piton A, Poynard T, Imbert-Bismut F, Khalil L, Delattre J, Pelissier E, Sansonetti N, Opolon P (1998). "Factors associated with serum alanine transaminase activity in healthy subjects: consequences for the definition of normal values, for selection of blood donors, and for patients with chronic hepatitis C. MULTIVIRC Group". Hepatology. 27 (5): 1213–9. doi:10.1002/hep.510270505. PMID 9581673.
  11. Kaplan MM (2002). "Alanine aminotransferase levels: what's normal?". Ann. Intern. Med. 137 (1): 49–51. PMID 12093245.
  12. Nannipieri M, Gonzales C, Baldi S, Posadas R, Williams K, Haffner SM, Stern MP, Ferrannini E (2005). "Liver enzymes, the metabolic syndrome, and incident diabetes: the Mexico City diabetes study". Diabetes Care. 28 (7): 1757–62. PMID 15983331.
  13. Liangpunsakul S, Chalasani N (2012). "What should we recommend to our patients with NAFLD regarding alcohol use?". Am. J. Gastroenterol. 107 (7): 976–8. doi:10.1038/ajg.2012.20. PMC 3766378. PMID 22764020.
  14. Cohen JA, Kaplan MM (1979). "The SGOT/SGPT ratio--an indicator of alcoholic liver disease". Dig. Dis. Sci. 24 (11): 835–8. PMID 520102.
  15. Schuppan D, Afdhal NH (2008). "Liver cirrhosis". Lancet. 371 (9615): 838–51. doi:10.1016/S0140-6736(08)60383-9. PMC 2271178. PMID 18328931.
  16. "EASL Clinical Practice Guidelines: management of cholestatic liver diseases". J. Hepatol. 51 (2): 237–67. 2009. doi:10.1016/j.jhep.2009.04.009. PMID 19501929.
  17. Sheth SG, Flamm SL, Gordon FD, Chopra S (1998). "AST/ALT ratio predicts cirrhosis in patients with chronic hepatitis C virus infection". Am. J. Gastroenterol. 93 (1): 44–8. doi:10.1111/j.1572-0241.1998.044_c.x. PMID 9448172.
  18. Williams AL, Hoofnagle JH (1988). "Ratio of serum aspartate to alanine aminotransferase in chronic hepatitis. Relationship to cirrhosis". Gastroenterology. 95 (3): 734–9. PMID 3135226.
  19. Wai CT, Greenson JK, Fontana RJ, Kalbfleisch JD, Marrero JA, Conjeevaram HS, Lok AS (2003). "A simple noninvasive index can predict both significant fibrosis and cirrhosis in patients with chronic hepatitis C". Hepatology. 38 (2): 518–26. doi:10.1053/jhep.2003.50346. PMID 12883497.
  20. Forns X, Ampurdanès S, Llovet JM, Aponte J, Quintó L, Martínez-Bauer E, Bruguera M, Sánchez-Tapias JM, Rodés J (2002). "Identification of chronic hepatitis C patients without hepatic fibrosis by a simple predictive model". Hepatology. 36 (4 Pt 1): 986–92. doi:10.1053/jhep.2002.36128. PMID 12297848.
  21. Vallet-Pichard A, Mallet V, Nalpas B, Verkarre V, Nalpas A, Dhalluin-Venier V, Fontaine H, Pol S (2007). "FIB-4: an inexpensive and accurate marker of fibrosis in HCV infection. comparison with liver biopsy and fibrotest". Hepatology. 46 (1): 32–6. doi:10.1002/hep.21669. PMID 17567829.
  22. Imbert-Bismut F, Ratziu V, Pieroni L, Charlotte F, Benhamou Y, Poynard T (2001). "Biochemical markers of liver fibrosis in patients with hepatitis C virus infection: a prospective study". Lancet. 357 (9262): 1069–75. doi:10.1016/S0140-6736(00)04258-6. PMID 11297957.
  23. Rosenberg WM, Voelker M, Thiel R, Becka M, Burt A, Schuppan D, Hubscher S, Roskams T, Pinzani M, Arthur MJ (2004). "Serum markers detect the presence of liver fibrosis: a cohort study". Gastroenterology. 127 (6): 1704–13. PMID 15578508.
  24. 24.0 24.1 Ellis G, Goldberg DM, Spooner RJ, Ward AM (1978). "Serum enzyme tests in diseases of the liver and biliary tree". Am. J. Clin. Pathol. 70 (2): 248–58. PMID 696683.
  25. Rong G, Wang H, Bowlus CL, Wang C, Lu Y, Zeng Z, Qu J, Lou M, Chen Y, An L, Yang Y, Gershwin ME (2015). "Incidence and risk factors for hepatocellular carcinoma in primary biliary cirrhosis". Clin Rev Allergy Immunol. 48 (2–3): 132–41. doi:10.1007/s12016-015-8483-x. PMID 25762349.
  26. Carr BI, Guerra V, Giannini EG, Farinati F, Ciccarese F, Ludovico Rapaccini G, Di Marco M, Benvegnù L, Zoli M, Borzio F, Caturelli E, Chiaramonte M, Trevisani F (2014). "Association of abnormal plasma bilirubin with aggressive hepatocellular carcinoma phenotype". Semin. Oncol. 41 (2): 252–8. doi:10.1053/j.seminoncol.2014.03.006. PMC 4009489. PMID 24787296.
  27. Goldberg DM (1980). "Structural, functional, and clinical aspects of gamma-glutamyltransferase". CRC Crit Rev Clin Lab Sci. 12 (1): 1–58. PMID 6104563.
  28. Barouki R, Chobert MN, Finidori J, Aggerbeck M, Nalpas B, Hanoune J (1983). "Ethanol effects in a rat hepatoma cell line: induction of gamma-glutamyltransferase". Hepatology. 3 (3): 323–9. PMID 6132864.
  29. Tanriverdi O (2014). "A discussion of serum albumin level in advanced-stage hepatocellular carcinoma: a medical oncologist's perspective". Med. Oncol. 31 (11): 282. doi:10.1007/s12032-014-0282-3. PMID 25316265.
  30. Chrostek L, Panasiuk A (2014). "Liver fibrosis markers in alcoholic liver disease". World J. Gastroenterol. 20 (25): 8018–23. doi:10.3748/wjg.v20.i25.8018. PMC 4081671. PMID 25009372.
  31. Papadakis MA, Fraser CL, Arieff AI (1990). "Hyponatraemia in patients with cirrhosis". Q. J. Med. 76 (279): 675–88. PMID 2217672.
  32. Qamar AA, Grace ND, Groszmann RJ, Garcia-Tsao G, Bosch J, Burroughs AK, Ripoll C, Maurer R, Planas R, Escorsell A, Garcia-Pagan JC, Patch D, Matloff DS, Makuch R, Rendon G (2009). "Incidence, prevalence, and clinical significance of abnormal hematologic indices in compensated cirrhosis". Clin. Gastroenterol. Hepatol. 7 (6): 689–95. doi:10.1016/j.cgh.2009.02.021. PMC 4545534. PMID 19281860.
  33. Triger DR, Wright R (1973). "Hyperglobulinaemia in liver disease". Lancet. 1 (7818): 1494–6. PMID 4123153.
  34. Bianchi G, Marchesini G, Zoli M, Bugianesi E, Fabbri A, Pisi E (1994). "Prognostic significance of diabetes in patients with cirrhosis". Hepatology. 20 (1 Pt 1): 119–25. PMID 8020880.
  35. Petrides AS, Vogt C, Schulze-Berge D, Matthews D, Strohmeyer G (1994). "Pathogenesis of glucose intolerance and diabetes mellitus in cirrhosis". Hepatology. 19 (3): 616–27. PMID 8119686.
  36. Warrell DA, Cox TN, Firth JD, Benz ED. Oxford textbook of medicine. Oxford: Oxford University Press, 2003. ISBN 0-19-262922-0.
  37. Runyon BA, Montano AA, Akriviadis EA, Antillon MR, Irving MA, McHutchison JG. The serum-ascites albumin gradient is superior to the exudate-transudate concept in the differential diagnosis of ascites. Ann Intern Med 1992;117:215-20. PMID 1616215.
  38. Halfon P, Munteanu M, Poynard T (2008). "FibroTest-ActiTest as a non-invasive marker of liver fibrosis". Gastroenterol Clin Biol. 32 (6): 22–39. doi:10.1016/S0399-8320(08)73991-5. PMID 18973844.



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