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    Evaluation of Abnormal Liver Chemistries (beta)

    Official guideline of the American College of Gastroenterology.

    Strength
    Strong recommendation
    Evidence
    Very low quality evidence

    Initial Assessment for both Acute and Chronic Abnormalities

    Initial Assessment for both Acute and Chronic Abnormalities
    1. Confirm​ abnormal LFTs (repeat labs and/or do confirmatory test).
    2. Obtain ​GGT if ALP high.
    3. Consider liver imaging (US or MRI).

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

    Hepatic
    1. 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.
    2. 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).
    3. 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.
    4. AIH​ – If positive AST and ALT, test ANA, ASMA, & globulin level.
    5. DILI ​– See chronic for details.
    6. Acute hepatitis ​– If acute hepatitis with elevated PT and/or encephalopathy, refer to liver specialist.
    Cholestatic
    1. DILI ​– See chronic for details.
    2. Obstruction ​– Obtain imaging. Start with abdominal US.
    3. Wilson’s​ – See chronic for details.

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

    Common
    1. HBV & HCV ​– See acute for details.
    2. NAFLD​ – If ⇧ ALT and metabolic syndrome, DM, HLD, HTN, overweight or obese, then liver ultrasound.
    3. ALD ​– If AST>ALT and drinking >140g/week (W) or >210g/week (M), counsel alcohol cessation.
    4. 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
    1. AIH​ – If ⇧ AST and ALT, then test ANA, ASMA, and globulin level.
    2. A1AT ​– If ⇧ AST and ALT, screen for A1AT phenotype.
    3. DILI ​– For ⇧ liver chemistries, obtain history of non-prescribed medications, complementary medicines, dietary or herbal supplements.
    4. 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.
    5. PBC ​– If ALP high, regardless of bilirubin, test for AMA.
    6. PSC ​– If ALP high, regardless of bilirubin, obtain MRCP or ERCP and IgG4.

    Other assessment

    Other assessment
    1. If labwork and imaging fail to diagnose or stage a condition, consider liver biopsy​.
    What do the icons mean?  
    Research PaperKwo PY, Cohen SM, Lim JK. Acg clinical guideline: evaluation of abnormal liver chemistries: American Journal of Gastroenterology. 2017;112(1):18-35.