MDCalc

Evaluation of Abnormal Liver Chemistries

Official guideline of the American College of Gastroenterology.

Initial Assessment for both Acute and Chronic Abnormalities

Initial Assessment for both Acute and Chronic Abnormalities
Strong recommendation
Very low quality evidence
Confirm​ abnormal LFTs (repeat labs and/or do confirmatory test).
Strong recommendation
Very low quality evidence
Obtain ​GGT if ALP high.
Strong recommendation
Very low quality evidence
Consider liver imaging (US or MRI).

If acute abnormalities repeat test negative, no further work-up. Otherwise:

Hepatic
Strong recommendation
Very low quality evidence
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.
Strong recommendation
Very low quality evidence
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).
Strong recommendation
Very low quality evidence
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.
Strong recommendation
Very low quality evidence
AIH​ – If positive AST and ALT, test ANA, ASMA, & globulin level.
Strong recommendation
Very low quality evidence
DILI ​– See chronic for details.
Strong recommendation
Very low quality evidence
Acute hepatitis ​– If acute hepatitis with elevated PT and/or encephalopathy, refer to liver specialist.
Cholestatic
Strong recommendation
Very low quality evidence
DILI ​– See chronic for details.
Strong recommendation
Very low quality evidence
Obstruction ​– Obtain imaging. Start with abdominal US.
Strong recommendation
Very low quality evidence
Wilson’s​ – See chronic for details.

If chronic abnormalities repeated and still present, still test for common diseases:

Common
Strong recommendation
Very low quality evidence
HBV & HCV ​– See acute for details.
Strong recommendation
Very low quality evidence
NAFLD​ – If ⇧ ALT and metabolic syndrome, DM, HLD, HTN, overweight or obese, then liver ultrasound.
Strong recommendation
Very low quality evidence
ALD ​– If AST>ALT and drinking >140g/week (W) or >210g/week (M), counsel alcohol cessation.
Strong recommendation
Very low quality evidence
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.
Rare
Strong recommendation
Very low quality evidence
AIH​ – If ⇧ AST and ALT, then test ANA, ASMA, and globulin level.
Strong recommendation
Very low quality evidence
A1AT ​– If ⇧ AST and ALT, screen for A1AT phenotype.
Strong recommendation
Very low quality evidence
DILI ​– For ⇧ liver chemistries, obtain history of non-prescribed medications, complementary medicines, dietary or herbal supplements.
Strong recommendation
Very low quality evidence
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.
Strong recommendation
Very low quality evidence
PBC ​– If ALP high, regardless of bilirubin, test for AMA.
Strong recommendation
Very low quality evidence
PSC ​– If ALP high, regardless of bilirubin, obtain MRCP or ERCP and IgG4.

Other assessment

Other assessment
Strong recommendation
Very low quality evidence
If labwork and imaging fail to diagnose or stage a condition, consider liver biopsy​.
Literature
Original/Primary Reference
Research PaperKwo PY, Cohen SM, Lim JK. Acg clinical guideline: evaluation of abnormal liver chemistries: American Journal of Gastroenterology. 2017;112(1):18-35.