Evaluation of Abnormal Liver Chemistries
Official guideline of the American College of Gastroenterology.
Initial Assessment for both Acute and Chronic Abnormalities
Confirm abnormal LFTs (repeat labs and/or do confirmatory test).
Obtain GGT if ALP high.
Consider liver imaging (US or MRI).
If acute abnormalities repeat test negative, no further work-up. Otherwise:
Hepatitis A and E – If acute hepatitis, test for acute HAV infection with HAV IgM. If HAV, HBV, HCV negative, and exposure to HEV endemic area, test for acute HEV infection with HEV IgM.
Hepatitis B – Screen chronic HBV with HBsAg. Test acute HBV with HBsAg and anti-HBc IgM. Test high risk groups (endemic areas, MSM, drug use, dialysis, HIV, pregnant women, close contacts of HBV-infected patients).
Hepatitis C – Screen baby boomers & high risk populations (drug use, tattoos, piercings, transfusions, and high risk sexual conduct) with anti-HCV. Confirm with HCV-RNA.
AIH – If positive AST and ALT, test ANA, ASMA, & globulin level.
DILI – See chronic for details.
Acute hepatitis – If acute hepatitis with elevated PT and/or encephalopathy, refer to liver specialist.
DILI – See chronic for details.
Obstruction – Obtain imaging. Start with abdominal US.
Wilson’s – See chronic for details.
If chronic abnormalities repeated and still present, still test for common diseases:
HBV & HCV – See acute for details.
NAFLD – If ⇧ ALT and metabolic syndrome, DM, HLD, HTN, overweight or obese, then liver ultrasound.
ALD – If AST>ALT and drinking >140g/week (W) or >210g/week (M), counsel alcohol cessation.
HH – If ⇧ liver chemistries without acute hepatitis, then test iron level, transferrin saturation, and serum ferritin. If transferrin saturation >45% and/or ⇧ ferritin, perform HFE gene mutation analysis.
AIH – If ⇧ AST and ALT, then test ANA, ASMA, and globulin level.
A1AT – If ⇧ AST and ALT, screen for A1AT phenotype.
DILI – For ⇧ liver chemistries, obtain history of non-prescribed medications, complementary medicines, dietary or herbal supplements.
Wilson’s – If ⇧ AST and ALT and age < 55, then screen for low serum ceruloplasmin. Confirm with 24-hour urinary copper and slit-lamp eye exam.
PBC – If ALP high, regardless of bilirubin, test for AMA.
PSC – If ALP high, regardless of bilirubin, obtain MRCP or ERCP and IgG4.
Other assessment
If labwork and imaging fail to diagnose or stage a condition, consider liver biopsy.
How strong is the ACG's recommendation?
