Abnormal LFTs Flashcards
Before initiation of evaluation of abnormal liver chemistries, one should repeat the lab panel.
strong, low evidence
Testing for chronic hepatitis C is done w/ anti-HCV and confirmation performed w/ HCV-RNA by nucleic acid testing. Risk factors for hepatitis C include history of IV or intranasal drug use, tattoos, body piercings, blood transfusions, high risk sexual conduct, those born between 1945 and 1965. Testing for acute hepatitis C is with anti-HCV and HCV RNA by nucleic acid testing.
strong, low evidence
Testing for chronic hepatitis B is done w/ HBsAG testing. Testing for acute hepatitis B is w/ HBsAg and IgM anti-HBc. The following groups are at highest risk: persons born in endemic or hyper endemic areas (HBsAG prevalence > 2%), men who have sex w/ men, persons who have used injection drugs, dialysis patients, HIV-infected patients, pregnancy women, and family members, household members, and sexual contacts of HBV-infected persons.
strong, low evidence
Testing for acute hepatitis A (IgM HAV) should occur in patients presenting w/ acute hepatitis and possible fecal-oral exposure. Testing for acute hepatitis E (IgM HEV) should also be considered in those returning from endemic areas and whose tests for acute hepatitis A, B, and C are negative.
strong, low evidence
Patients w/ elevated BMI and other features of metabolic syndrome with mild elevations of ALT should undergo screening for NAFLD w/ ultrasound.
strong, low evidence
Women consuming more than 140g per week or men more than 210g per week who present w/ AST>ALT should be considered at risk for alcoholic liver disease and should be counseled for alcohol cessation.
strong, low evidence
Patient w/ abnormal liver chemistries in the absence of acute hepatitis should undergo testing for hereditary hemochromatosis w/ an iron level, transferrin saturation, and serum ferritin. HFE gene mutation analysis should be performed in patients w/ transferrin saturation >/= 45% and/or elevated serum ferritin.
strong, low evidence
Patients w/ abnormal AST and ALT levels, particularly w/ other autoimmune conditions, should undergo testing for autoimmune liver disease including ANA, ASMA, and globulin level.
strong, low evidence
Patients w/ persistently elevated AST and ALT levels, especially patients < 55 years of age, should undergo screening for Wilson’s disease w/ serum ceruloplasmin. In a low ceruloplasmin, confirmatory testing w/ 24-h urinary copper and slit-lamp eye examination should occur.
strong, low evidence
Patient w/ persistently elevated AST or ALT should undergo screening for alpha-1 anti-trypsin deficiency w/ alpha-1 anti-trypsin phenotype.
strong, low evidence
A liver biopsy may be considered when serologic testing and imaging fails to elucidate a diagnosis or when multiple diagnoses are possible.
strong, low evidence
An elevation of alkaline phosphatase should be confirmed w/ an elevation in GGT. Given its lack of specificity for liver disease, GGT should not be used as a screening test for underlying liver disease in the absence of other abnormal liver chemistries.
strong, low evidence
Patient w/ alkaline phosphatase elevation w/ or w/o elevation of bilirubin should undergo testing for PBC w/ testing for anti-mitochondrial antibody.
strong, low evidence
Patients w/ alkaline phosphatase elevation w/ or w/o elevation of bilirubin should undergo testing for PSC w/ MR cholangiography or ERCP in conjunction w/ IgG4.
strong, low evidence
In those w/ ALT and/or AST levels <5x ULN, the history and lab testing should assess for viral hepatitis B and C, alcoholic and NAFLD, hemochromatosis, Wilson’s disease, alpha-1-anti-trypsin deficiency, autoimmune hepatitis and consider drugs/supplement related injury.
strong, low evidence
In those w/ ALT and/or AST levels 5-15x ULN, evaluation should also assess for acute hepatitis A, B, and C in addition to all etiologies for AST/ALT elevation less than 5x ULN.
strong, low evidence
In those w/ ALT and/or AST levels >15x ULN, or massive elevation ALT of >10,000, evaluation should also assess for acetaminophen toxicity and ischemic hepatopathy.
strong, low evidence
A patient presenting w/ acute hepatitis w/ an elevated prothrombin time, and/or encephalopathy requires immediate referral to liver specialist.
strong, low evidence
