From the Guidelines
For a young female with abnormal liver function tests, I recommend starting with a comprehensive evaluation that includes both laboratory and imaging studies, as outlined in the most recent guidelines from 2023 1. Begin with a complete blood count, comprehensive metabolic panel, and a hepatitis panel (A, B, and C). Order specific liver tests including alkaline phosphatase, GGT, bilirubin (total and direct), albumin, and prothrombin time to assess liver synthetic function.
Initial Laboratory Tests
- Complete blood count
- Comprehensive metabolic panel
- Hepatitis panel (A, B, and C)
- Alkaline phosphatase
- GGT
- Bilirubin (total and direct)
- Albumin
- Prothrombin time Autoimmune markers should be checked, including antinuclear antibody, anti-smooth muscle antibody, anti-liver kidney microsomal antibody, and immunoglobulin levels, as young females have higher rates of autoimmune hepatitis.
Autoimmune Markers
- Antinuclear antibody
- Anti-smooth muscle antibody
- Anti-liver kidney microsomal antibody
- Immunoglobulin levels Test for Wilson's disease with serum ceruloplasmin and copper levels. Check iron studies (ferritin, transferrin saturation) to rule out hemochromatosis.
Additional Tests
- Serum ceruloplasmin and copper levels for Wilson's disease
- Iron studies (ferritin, transferrin saturation) for hemochromatosis Obtain an abdominal ultrasound to evaluate liver structure, rule out biliary obstruction, and assess for fatty liver. If there's a history of alcohol use, calculate the AST/ALT ratio.
Imaging Studies
- Abdominal ultrasound Consider testing for celiac disease with tissue transglutaminase antibodies, as it can cause liver abnormalities. Alpha-1 antitrypsin levels should be measured if there's a family history of liver disease.
Special Considerations
- Tissue transglutaminase antibodies for celiac disease
- Alpha-1 antitrypsin levels for family history of liver disease This comprehensive approach is necessary because liver function abnormalities in young females can stem from various causes including autoimmune conditions, medication effects, viral hepatitis, metabolic disorders, and anatomical issues, requiring thorough investigation for proper diagnosis and management, as supported by previous guidelines 1.
From the Research
Initial Evaluation
The initial evaluation for a young female with abnormal liver function test results should include:
- A review of previous laboratory test results, medical and family histories, substance use, and drugs, including over-the-counter drugs and herbal supplements 2
- A physical examination, which may be normal but can also show findings consistent with acute disease 2
- A complete blood cell count; alanine aminotransferase, aspartate aminotransferase, alkaline phosphatase, total bilirubin, and albumin levels; prothrombin time; hepatitis B surface antigen; hepatitis B core antibody; hepatitis C antibody; ferritin and iron levels and transferrin saturation; and right upper quadrant abdominal ultrasonography 2
Pattern of Abnormal Liver Test Results
The pattern and severity of liver injury can provide clues about the cause of disease and should guide diagnostic evaluation with serologic testing and liver imaging 3
- Hepatocellular injury is defined as disproportionate elevation of AST and ALT levels compared with alkaline phosphatase levels 4
- Cholestatic injury is defined as disproportionate elevation of alkaline phosphatase level as compared with AST and ALT levels 4
Additional Tests
Additional tests and imaging should be based on patient-specific risk factors and the pattern of abnormal liver test results 2
- For the evaluation of hepatocellular injury, testing for viral hepatitis A, B, and C, assessment for nonalcoholic fatty liver disease and alcoholic liver disease, screening for hereditary hemochromatosis, autoimmune hepatitis, Wilson's disease, and alpha-1 antitrypsin deficiency should be considered 4
- For the evaluation of an alkaline phosphatase elevation determined to be of hepatic origin, testing for primary biliary cholangitis and primary sclerosing cholangitis should be undertaken 4
- A liver biopsy may be considered when serologic testing and imaging fails to elucidate a diagnosis, to stage a condition, or when multiple diagnoses are possible 4