From the Guidelines
For elevated liver function tests (LFTs) with abdominal pain, I recommend a systematic approach starting with a thorough history and physical examination, as the most recent and highest quality study suggests that imaging plays an essential role in narrowing the differential diagnosis and directing management 1. Initial laboratory testing should include a complete liver panel (ALT, AST, alkaline phosphatase, GGT, bilirubin, albumin), complete blood count, basic metabolic panel, coagulation studies (PT/INR), and lipase/amylase. Some key points to consider in the initial evaluation include:
- The severity of abnormal aminotransferase can be classified as mild, moderate, or severe, with moderate and severe being discussed collectively due to significant clinical overlap 1
- Pathologically increased levels of ALP may occur in cholestatic liver disease, which can show elevated ALP with or without elevated bilirubin 1 Imaging should begin with a right upper quadrant ultrasound to evaluate for biliary obstruction, gallstones, liver parenchymal disease, and ascites, as ultrasound is the first choice of investigation for biliary symptoms or right upper quadrant abdominal pain 1. If the ultrasound is inconclusive, proceed to CT abdomen with contrast or MRI/MRCP depending on the suspected etiology. Additional testing may include:
- Viral hepatitis serologies (HAV, HBV, HCV)
- Autoimmune markers (ANA, ASMA, AMA)
- Iron studies
- Ceruloplasmin (Wilson's disease)
- Alpha-1 antitrypsin levels
- Drug/toxin screens For patients with significant alcohol consumption, consider alcoholic hepatitis. If biliary obstruction is identified, ERCP may be necessary for both diagnosis and intervention. For autoimmune hepatitis, prednisone 40-60mg daily with azathioprine 50-150mg daily may be indicated. This comprehensive approach is necessary because elevated LFTs with abdominal pain can result from various conditions including viral hepatitis, drug-induced liver injury, alcoholic or non-alcoholic fatty liver disease, biliary obstruction, autoimmune hepatitis, or ischemic hepatitis, each requiring different management strategies 1.
From the Research
Evaluation of Elevated LFTs in Abdominal Pain
- The evaluation of abnormal liver function tests (LFTs) in patients with abdominal pain should be organized into four steps 2
- The first step is to determine whether the abnormal LFTs are associated with the illness resulting in the admission to the hospital or preceded the present illness 2
- The second step is to determine the etiology of the underlying liver disease, which can include conditions such as cholecystitis 3
- The third step is to evaluate the severity of the liver dysfunction and determine if acute liver failure (ALF) or acute decompensation of chronic liver failure is present 2
Role of Liver Function Tests in Diagnosing Cholecystitis
- Liver function tests can be useful in diagnosing cholecystitis, but normal liver function does not exclude the condition 3
- In patients with suspected cholecystitis, 69.9% had some evidence of liver dysfunction, and the presence of ductal calculi was associated with a significantly increased incidence of liver dysfunction 3
- The predictive value of a negative liver function test is low (30.3%), which means that normal liver function tests do not rule out cholecystitis 3
Investigative Protocol
- An investigative protocol can be proposed based on the information obtained from the study, which may substantially reduce the rate of misdiagnosis of patients with abdominal pain suggestive of cholelithiasis 3
- This protocol should take into account the clinical presentation, laboratory results, and imaging studies to determine the underlying cause of the abdominal pain and elevated LFTs 2, 3