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elevated serum transaminases; transaminitis; abnormal liver function tests

Classification: - mild elevation: 2 to 5 times the upper limit of normal. Etiology: - non-alcoholic fatty liver disease - diabetes mellitus, metabolic syndrome - alcohol consumption - dietary supplements - hepatitis - hepatitis B, hepatitis C, autoimmunwe hepatitis - hemochromatosis - adult-onset Still's disease - hepatolenticular degeneration - polycystic ovary disease History: - review medications a) prescription b) non-prescription c) herbs d) illicit drugs Physical examination: 1) stigmata of liver disease 2) evidence of alcoholism Laboratory: 1) serum transaminases (serum AST, serum ALT) - repeat after 1 month of lifestyle changes, see management (below) - repeat after additional 3 months if diagnosis unclear 2) comprehensive metabolic panel a) serum alkaline phosphatase (serum ALP) b) serum bilirubin 3) hepatitis B serology, hepatitis C serology 4) lipid panel 5) hemoglobin A1c 6) iron studies, serum iron, TIBC, serum ferritin 7) prothrombin time (INR) 8) complete blood count 6) antinuclear antibody (ANA) in women Radiology: - abdominal ultrasound Differential diagnosis: 1) alcoholic liver disease a) occurs in a minority of alcoholics b) typically AST will be: 1] 2-5 times the upper limit of normal 2] more than double to ALT 2) chronic hepatitis B or hepatitis C a) parenteral drug abuse b) prior blood transfusion (especially HCV) c) Asian nationality 3) hemochromatosis a) occurs in 0.3% of population b) elevated serum ferritin & transferrin saturation (>60%) c) liver biopsy or genetic testing 4) hepatotoxicity - large number of medicines & herbs 5) autoimmune hepatitis a) rare disorder b) occurs mostly in women c) measure antinuclear antibody (ANA) (there are false negatives) 6) fatty liver a) most common cause of elevated LFTs if 1-5 above ruled out b) typically ALT is 1.5-4 x upper limit of normal c) minimal if any abnormalities in AST & ALP Management: - lifestyle modifications: (mild elevation) - identify risk factors & address - discontinue alcohol, supplements & potentially heptotoxic medications - repeat serum transaminase testing in 1 month

Related

alanine aminotransferase (ALT) in serum/plasma (SGPT) aspartate aminotransferase (AST) in serum (SGOT) liver (function) tests (LFT, liver panel, hepatic function panel)

General

abnormal blood chemistry test

References

  1. Leung KK, Hirschfield GM Elevated Serum Aminotransferases JAMA. 2022;327(6):580-581 PMID: 35133427 https://jamanetwork.com/journals/jama/fullarticle/2788800
  2. Kaiser Permanente Nothern California, Lab Tips, Sept. 1999
  3. Gandhi P, Latifi N. Mild Transaminase Elevation With Rapid Diagnostic Escalation. A Teachable Moment. JAMA Intern Med. Published online August 14, 2023 PMID: 37578790 https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/2808087