From the Guidelines
Elevated liver enzymes in pediatric patients require prompt evaluation to determine the underlying cause, and initial management should include a thorough history and physical examination, as well as laboratory testing, with referral to a pediatric gastroenterologist for significant elevations. The most recent and highest quality study 1 provides guidance on the management of abnormal liver function tests, emphasizing the importance of determining the underlying cause of liver enzyme elevation. Common causes in children include viral hepatitis, medication effects, autoimmune hepatitis, metabolic disorders, and non-alcoholic fatty liver disease.
- Key considerations in the evaluation of pediatric patients with elevated liver enzymes include:
- Thorough history and physical examination, focusing on symptoms like jaundice, abdominal pain, fatigue, and recent medication use
- Laboratory testing, including a comprehensive metabolic panel, complete blood count, and specific liver function tests
- Referral to a pediatric gastroenterologist for significant elevations or persistent abnormalities
- The study by Newsome et al. 1 highlights the importance of investigating the etiology of abnormal liver blood tests, rather than simply repeating the tests, and notes that a low threshold for referral to a pediatrician is warranted in children due to the wider differential diagnosis.
- Another study 1 recommends considering Wilson disease in the differential diagnosis of patients presenting with nonalcoholic fatty liver disease or atypical autoimmune hepatitis.
- The most recent study 1 provides an update on the diagnosis and management of abnormal liver function tests, including the use of imaging and liver biopsy in certain cases.
- The study by Sokal et al. 1 provides guidance on the management of chronic hepatitis B in childhood, including the decision to treat and the use of antiviral therapy.
- In terms of specific management, discontinuation of hepatotoxic medications is essential if drug-induced liver injury is suspected, and supportive care includes adequate hydration and nutrition. The liver has remarkable regenerative capacity, and many cases of transient enzyme elevation resolve with appropriate management of the underlying cause. Persistent or severe elevations may require liver biopsy for definitive diagnosis.
From the Research
Elevated Liver Enzymes in Pediatric Patients
Elevated liver enzymes in pediatric patients can be caused by various factors, including hepatic and extrahepatic diseases, as well as transient and chronic liver conditions 2. The differential diagnosis is broad, and a systematic approach is essential to evaluate abnormal liver enzymes in asymptomatic children.
Causes of Elevated Liver Enzymes
Some possible causes of elevated liver enzymes in pediatric patients include:
- Celiac disease, which can cause elevated liver enzymes in approximately 25% of newly diagnosed patients 3
- Nonalcoholic fatty liver disease (NAFLD), which is the most common cause of elevated liver enzymes in children in the United States 4
- Inflammatory bowel disease (IBD), which can cause elevated liver enzymes in approximately 41% of patients 5
- Blunt abdominal trauma, which can result in liver injury and elevated liver enzymes 6
Evaluation and Diagnosis
The evaluation of elevated liver enzymes in pediatric patients should include:
- A complete history and physical examination to exclude red flags and dictate urgent consultation with a pediatric gastroenterologist or hepatologist 2
- Laboratory tests, such as liver enzyme panels and exclusionary testing, to determine the underlying cause of elevated liver enzymes 3, 4, 5
- Imaging studies, such as abdominal CT, to evaluate liver injury in patients with blunt abdominal trauma 6
Management and Treatment
The management and treatment of elevated liver enzymes in pediatric patients depend on the underlying cause and may include:
- A gluten-free diet for patients with celiac disease 3
- Lifestyle modifications, such as weight loss and exercise, for patients with NAFLD 4
- Medications and other treatments for patients with IBD 5
- Monitoring and follow-up to ensure that liver enzymes return to normal and to detect any potential complications 2, 3, 4, 5, 6