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
  • prescription
  • non-prescription
  • herbs
  • illicit drugs

Physical examination

• stigmata of liver disease
• evidence of alcoholism

Laboratory

• serum transaminases (serum AST, serum ALT)
  • repeat after 1 month of lifestyle changes, see management (below)
  • repeat after additional 3 months if diagnosis unclear
• comprehensive metabolic panel
  • serum alkaline phosphatase (serum ALP)
  • serum bilirubin
• hepatitis B serology, hepatitis C serology
• lipid panel
• hemoglobin A1c
• iron studies, serum iron, TIBC, serum ferritin
• prothrombin time (INR)
• complete blood count
• antinuclear antibody (ANA) in women

Radiology

• abdominal ultrasound

Differential diagnosis

• alcoholic liver disease
  • occurs in a minority of alcoholics
  • typically AST will be:
    • 2-5 times the upper limit of normal
    • more than double to ALT
• chronic hepatitis B or hepatitis C
  • parenteral drug abuse
  • prior blood transfusion (especially HCV)
  • Asian nationality
• hemochromatosis
  • occurs in 0.3% of population
  • elevated serum ferritin & transferrin saturation (>60%)
  • liver biopsy or genetic testing
• hepatotoxicity - large number of medicines & herbs
• autoimmune hepatitis
  • rare disorder
  • occurs mostly in women
  • measure antinuclear antibody (ANA) (there are false negatives)
• fatty liver
  • most common cause of elevated LFTs if 1-5 above ruled out
  • typically ALT is 1.5-4 x upper limit of normal
  • 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

More general terms

• abnormal blood chemistry test

Additional terms

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