LFT Pattern Recognition Masterclass for MRCP Part 1
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LFT Pattern Recognition Masterclass for MRCP Part 1

TL;DR:

 This clinician-written guide explains how to recognise liver function test (LFT) patterns quickly and accurately for MRCP Part 1. It focuses on high-yield patterns, common exam traps, and a simple interpretation algorithm, supported by a mini-case and a practical revision checklist. Use this alongside structured question practice to convert pattern recognition into exam marks.


Why LFT pattern recognition matters in MRCP Part 1

Abnormal liver function tests are a staple of MRCP Part 1 because they assess clinical reasoning under time pressure. The exam rarely rewards listing long differentials; instead, it tests whether you can identify the dominant biochemical pattern and link it to the most likely diagnosis in context.

Candidates often lose marks by:

  • Focusing on single values rather than overall patterns

  • Misclassifying mixed abnormalities

  • Ignoring ratios (particularly AST:ALT)

  • Forgetting that bilirubin and synthetic markers reflect different pathology

A disciplined, pattern-first approach dramatically improves accuracy.

For syllabus context, see the official MRCP(UK) guidance:https://www.mrcpuk.org/mrcpuk-examinations/part-1


Scope of this masterclass

This article is designed as hub-support content for MRCP Part 1 hepatology and covers:

  • The four core LFT patterns tested in the exam

  • Five most frequently tested subtopics

  • Five high-yield traps that cost marks

  • One short exam-style case with explanation

  • A practical, exam-ready revision checklist

For structured revision and exam-standard questions, integrate this with:

The four core LFT patterns you must recognise

1. Hepatocellular pattern

  • Dominant abnormality: ALT and AST

  • Typical causes: Acute viral hepatitis, drug-induced liver injury, ischaemic hepatitis

  • Exam clue: ALT usually higher than AST (except in alcohol-related disease)

2. Cholestatic pattern

  • Dominant abnormality: Alkaline phosphatase (ALP) ± GGT

  • Typical causes: Gallstones, primary biliary cholangitis, pancreatic or biliary malignancy

  • Exam clue: Pruritus, pale stools, dark urine

3. Mixed pattern

  • Dominant abnormality: Both transaminases and ALP raised

  • Typical causes: Drug-induced liver injury, sepsis-associated cholestasis

  • Exam clue: Recent antibiotics or systemic illness

4. Isolated hyperbilirubinaemia

  • Dominant abnormality: Bilirubin only

  • Typical causes: Gilbert syndrome, haemolysis

  • Exam clue: Normal ALT, AST, and ALP


High-yield LFT comparison table

Pattern

ALT/AST

ALP

Bilirubin

Classic MRCP diagnosis

Hepatocellular

↑↑

Normal/mild ↑

Variable

Acute viral hepatitis

Alcohol-related

AST > ALT (~2:1)

Mild ↑

↑

Alcohol-related liver disease

Cholestatic

Mild ↑

↑↑

↑

Extrahepatic obstruction

Infiltrative

Normal/mild ↑

↑↑

Normal/mild ↑

Metastatic liver disease

Isolated bilirubin

Normal

Normal

↑

Gilbert syndrome

Exam tip: Always identify the dominant enzyme abnormality first. Most MRCP errors occur before this step is done correctly.


Five most tested LFT subtopics

1. AST:ALT ratio

  • >2:1 strongly suggests alcohol-related liver disease

  • Due to mitochondrial AST release and pyridoxal-5-phosphate deficiency

2. GGT interpretation

  • Confirms hepatic origin of raised ALP

  • Raised with alcohol excess and enzyme induction

  • Not a screening test for alcohol misuse on its own

3. Ischaemic hepatitis (“shock liver”)

  • AST and ALT often >1000 IU/L

  • Rapid rise and rapid fall

  • Context: hypotension, cardiac arrest, severe sepsis

4. Cholestasis vs obstruction

  • Extrahepatic obstruction: ALP and bilirubin markedly raised

  • Intrahepatic cholestasis: ALP raised, bilirubin variably raised, ALT mild

5. Synthetic function (commonly tested with LFTs)

  • Albumin: reflects chronic disease or inflammation

  • INR: best marker of acute liver synthetic failure

One-minute LFT interpretation algorithm (exam-safe)

  1. Identify the dominant abnormality (ALT/AST vs ALP vs bilirubin)

  2. Check the AST:ALT ratio

  3. Use GGT to confirm hepatic ALP

  4. Assess bilirubin type (conjugated vs unconjugated)

  5. Apply clinical context (alcohol, drugs, sepsis, hypotension)

This mirrors how MRCP Part 1 questions are constructed.


Doctor preparing for MRCP Part 1 using online question bank and mock tests

Mini-case (exam style)

Question A 52-year-old man presents with lethargy. Blood tests show:

  • ALT 78 IU/L

  • AST 165 IU/L

  • ALP 118 IU/L (normal)

  • Bilirubin 32 µmol/L

  • MCV is raised

What is the most likely diagnosis?

Answer and explanation The AST:ALT ratio is >2:1 with macrocytosis and mild hyperbilirubinaemia, indicating a hepatocellular pattern consistent with alcohol-related liver disease. Viral hepatitis typically shows ALT > AST.

Exam pearl: Ratios and patterns matter more than absolute numbers.


Five common MRCP Part 1 traps

  • Interpreting ALP without checking GGT

  • Labelling mild ALP rise as “cholestatic” despite ALT dominance

  • Missing ischaemic hepatitis due to lack of haemodynamic context

  • Assuming normal bilirubin excludes significant liver disease

  • Forgetting INR and albumin when severity is asked


Practical study checklist (use before exam)

  • ☐ Memorise the four LFT patterns, not long differentials

  • ☐ Practise AST:ALT ratio recognition repeatedly

  • ☐ Link each pattern to a classic vignette

  • ☐ Complete timed hepatology blocks from a question bank

  • ☐ Validate under pressure using a full mock test

For structured explanation and reinforcement, combine this with hepatology lectures:https://crackmedicine.com/lectures/


FAQs (People Also Ask)

How common are LFT questions in MRCP Part 1?

They appear frequently, often embedded in gastroenterology, infectious disease, or systemic illness vignettes.

Do I need to memorise exact enzyme cut-offs?

No. The exam focuses on relative patterns and ratios, not precise thresholds.

Is GGT a reliable marker of alcohol misuse?

It supports hepatic origin of ALP but is nonspecific; MRCP uses it as a confirmatory enzyme only.

Are albumin and INR considered LFTs in the exam?

They are often included to assess chronicity and severity, even though they are synthetic function markers.


Ready to start?

Apply this LFT pattern-recognition framework immediately with exam-standard practice.👉 Practise targeted hepatology questions now: https://crackmedicine.com/qbank/

Once confident, assess your readiness under real exam conditions:👉 Take a full MRCP Part 1 mock test: https://crackmedicine.com/mock-tests/


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