Mildly Elevated Liver Transaminase Levels in the
Asymptomatic Patient
AFP March 15, 2005, Vol. 71, No. 6; Green RM, Flamm S.
AGA technical review on the evaluation of liver chemistry tests.
Gastroenterology 2002; 123: 1367-84.
Note: ALT is thought to be more specific than AST for hepatic injury
because it is present mainly in the cytosol of the liver and in low
concentrations elsewhere.
Management:
H & P:
- Family history, medications, vitamins, herbal supplements, drug use,
alcohol use, abnormal liver testing, blood-product transfusions, symptoms of
liver disease; diabetes, heart disease, thyroid disease, muscle disease,
cancer
Labs
- Ferritin, TIBC, Serum Iron - r/o hemochromatosis
- Hep A, B, C - r/o active/chronic hepatitis
- PT, albumin - r/o abnormalities of protein synthesis and lvier function
- CBC - r/o infection; neutropenia and thrombocytopenia may suggest advanced
liver disease
- elevated mean red cell volume suggests heavy alcohol intake
- Alkaline phosphatase and bilirubin are markers for hepatic cholestasis
Lifestyle Modification
- abstain from alcohol
- control diabetes and hyperlipidemia
- weight loss in overweight patients
- stopping or changing potentially hepatotoxic medications and supplements
Follow up and Imaging
- Repeat LFTs after 6 months or shorter if rpesentation changes or concern
for an evolving process
- If elevated enzymes persist, Ultrasound liver - r/o steatosis,
steatohepatitis
If U/S is negative
- alpha1-antitrypsin (alpha1-antitrypsin)
- serum ceruloplasmin (Wilson's disease)
- antigliadin and anti-endoysial antibody (celiac disease)
- ANA, anti-smooth-muscle Ab (autoimmune hepatitis)
Liver biopsy?
- individual basis - consider age, lifestyle, liver chemistry abnormalities,
associated comorbidities
- only with chronic mild transaminase elevations would be an asymptomatic
patient be considered a possible candidate for biopsy
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Etiology when less than 5X normal
Common hepatic causes:
- Alcohol
- Cirrhosis
- Hepatitis B (Chronic)
- Hepatitis C (Chronic)
- Steatosis/ steatohepatitis
- Medications/ toxins
- Acute Viral Hepatitis
Less common hepatic causes
- Autoimmune hepatitis
- Hemochromatosis
- Alpha1-antitrypsin deficiency
- Wilson's disease
Nonhepatic causes
- Celiac disease
- Hemolysis
- Myopathy
- Hyperthyroidism
- Strenous exercise
- Macro-AST