From the Guidelines
The next step for a patient with elevated liver enzymes (AST 58 and ALT 114) without abdominal pain would be to repeat the liver function tests in 2-4 weeks to determine if these abnormalities persist, as recommended by the most recent guidelines 1. This approach is supported by the fact that mild elevations in liver enzymes can be transient and may not necessarily indicate a serious underlying condition.
- A comprehensive hepatic panel, including alkaline phosphatase, bilirubin, albumin, and prothrombin time, should be ordered to assess liver function more thoroughly 1.
- A thorough history should be obtained regarding alcohol use, medications (including over-the-counter drugs and supplements), recent illnesses, and family history of liver disease, as these factors can contribute to elevated liver enzymes 1.
- If the elevated enzymes persist on repeat testing, further evaluation with hepatitis serology (hepatitis A, B, and C), iron studies, autoimmune markers (ANA, anti-smooth muscle antibody), and an ultrasound of the liver would be appropriate, as suggested by the American College of Radiology 1. The mild elevation of transaminases with ALT higher than AST suggests a hepatocellular pattern of injury rather than cholestatic or infiltrative disease, which is commonly seen in viral hepatitis, medication-induced liver injury, and early stages of fatty liver disease 1. According to the AGA clinical practice update on the role of noninvasive biomarkers in the evaluation and management of nonalcoholic fatty liver disease, patients with clinical suspicion of NAFLD should undergo further evaluation, including screening and/or serologic evaluation for alternate causes of chronic hepatitis 1. The patient's liver enzymes should be monitored, and lifestyle modifications should be recommended to prevent progression of potential liver disease, as suggested by the most recent guidelines 1.
From the Research
Laboratory Results
- AST: 58
- ALT: 114
- Other lab work: unremarkable
- No abdominal pain
Possible Next Steps
- Further evaluation to determine the cause of elevated liver enzymes, as the current lab work is unremarkable and there is no abdominal pain 2
- Consider imaging studies, such as ultrasound, to rule out other possible causes of chronic liver disease and to detect any potential complications 3, 4
- Sequential measurement of relevant autoantibodies and liver histology may be necessary to facilitate diagnosis 2
- Immunosuppressive therapy may be considered if autoimmune hepatitis is suspected, as it has been shown to prevent or stop the development of cirrhosis and improve prognosis 2, 5