Patients presenting with raised tumour markets (AFP, CEA, CA19-9) may have relatively few symptoms.
However, a history of hepatitis B or C, significant alcohol intake and family history of hepatoma would be pertinent in patients with a raised AFP. Besides, through abdominal examination, inspection of the testes in men to exclude non-seminomatous germ cell tumours is useful. Further investigations would include a transabdominal ultrasound and upper gastrointestinal endoscopy would be required in the evaluation of patients with a raised AFP.
If the patient has a raised CEA, a history of smoking and symptoms suggestive of colorectal (per rectum bleeding, change in bowel habits) and lung (cough, hemoptysis) malignancy needs to be inquired for. Cross-sectional imaging (CT, MRI) of the thorax, abdomen and pelvis followed by endoscopy (gastroscopy, colonoscopy) should be performed where appropriate. Patients with a raised CA19-9 would require cross-sectional imaging to exclude pancreatic and biliary malignancy and a gastroscopy and colonoscopy where appropriate.
Patients with anaemia may be asymptomatic or may experience fatigue, have palpitations or become short of breath.
Symptoms of excessive blood loss (gastrointestinal-per-rectal bleeding, malena or excessive menstruation) should be elucidated. A dietary history is essential. Further evaluation would depend on the likely cause of anaemia and may include endoscopy or referral to a dietician or gynaecologist.
If the predominant problem is that of an abnormal liver function test results, the evaluation would require a complete history of one’s lifestyle (including recent travel, transfusions, unprotected sexual intercourse, alcohol intake, diabetes mellitus, obesity, hyperlipidemia, family history) and a thorough clinical examination for stigmata of chronic liver disease, hepatosplenomegaly, ascites and obesity.
The diagnostic algorithm would depend on the predominant problem, for example the exclusion of hemolysis for isolated hyperbilirubinemia is important. However, if the main problem is that of a ‘hepatitic picture’, on liver function tests, viral serology eg. Hepatitis B & C, cytomegalovirus (CMV), Epstein-Barr virus and possibly HIV may be more appropriate. Autoantibody screen eg. antimitochandrial antibody, anti-smooth muscle antibody and antinuclear antibody should be performed. Exclusion of Wilson’s disease or Glycogen Storage disease would be appropriate in some circumstances.
Transabdominal ultrasound is noninvasive and a useful screening test to detect structural abnormalities before more detailed cross-sectional imaging (CT, MRI, MRCP) is ordered.