What are the next steps for a patient with elevated liver enzymes and urinary abnormalities?

From the Guidelines

For a patient with elevated liver enzymes and urinary abnormalities, the next steps should include a thorough clinical history and targeted physical examination to identify the underlying cause, followed by a standard liver aetiology screen or core panel to exclude additional pathologies. This approach is supported by the guidelines on the management of abnormal liver blood tests, which emphasize the importance of determining the cause of liver enzyme elevations rather than simply repeating the tests 1.

The clinical history should include age, ethnicity, specific symptoms such as jaundice or abdominal pain, comorbidity, drug history, travel history, and family history, as these factors can help identify potential causes of liver dysfunction 1. The physical examination should include an assessment of body mass index and an abdominal examination to look for signs of chronic liver disease such as hepatosplenomegaly or ascites.

Key investigations should include:

• A standard liver aetiology screen or core panel to identify the cause of damage and exclude additional pathologies
• Complete liver panel (ALT, AST, alkaline phosphatase, bilirubin, albumin, and prothrombin time)
• Complete urinalysis with microscopic examination
• Renal function tests (BUN, creatinine, eGFR)
• Imaging studies such as an abdominal ultrasound to evaluate liver structure and rule out biliary obstruction

Depending on the initial findings, further specialized tests may be needed, such as viral hepatitis serologies or autoimmune markers 1. If urinary abnormalities suggest glomerular disease and liver involvement persists without clear etiology, conditions like hepatorenal syndrome or systemic diseases affecting both organs should be considered. Referral to specialists may be warranted for coordinated care. Patients should temporarily avoid alcohol, hepatotoxic medications, and maintain adequate hydration while awaiting definitive diagnosis and treatment plan.

From the FDA Drug Label

Abnormalities in liver enzymes have not been associated with Ursodiol therapy and, in fact, Ursodiol has been shown to decrease liver enzyme levels in liver disease. However, patients given Ursodiol should have SGOT (AST) and SGPT (ALT) measured at the initiation of therapy and thereafter as indicated by the particular clinical circumstances

The next steps for a patient with elevated liver enzymes and urinary abnormalities are to:

• Monitor liver enzyme levels (SGOT and SGPT) as indicated by the clinical circumstances
• Consider the potential interaction between Ursodiol and other medications, such as bile acid sequestering agents or estrogens
• Be cautious when administering Ursodiol to patients with liver disease or those who may have a congenital or acquired deficiency in sulfation 2

From the Research

Next Steps for Patients with Elevated Liver Enzymes and Urinary Abnormalities

The next steps for a patient with elevated liver enzymes and urinary abnormalities involve a series of diagnostic evaluations to determine the underlying cause of the abnormalities.

• The initial step is to perform liver function tests, which include biochemical parameters such as AST, ALT, GGT, alkaline phosphatase, bilirubin, and albumin levels, as well as coagulation tests like prothrombin activity 3.
• The pattern of liver test abnormalities can suggest the category of the underlying liver disease, such as hepatitis, biliary obstructions, or infiltrative liver disease 4.
• If the patient has cytolytic elevation in serum aminotransferases, the next step is to exclude pharmacological toxicity, viral hepatitis, alcoholic and non-alcoholic fatty liver disease, and hemochromatosis 3.
• For cholestatic elevation of serum enzymes, it is essential to establish the origin of the alkaline phosphatase elevation and evaluate the GGT levels to confirm the hepatic origin 3.
• Abdominal ultrasound is a crucial test to evaluate the biliary system and distinguish between extrahepatic and intrahepatic cholestasis 3, 5.
• The evaluation of albumin and prothrombin levels helps to assess the hepatic function and differentiate between acute and chronic diseases 3.
• In some cases, more specialized serum tests and liver biopsy may be necessary to establish a precise diagnosis 4, 5.
• Ultrasonography is the best initial imaging technique for the liver, and if biliary dilatation is noted, endoscopic retrograde cholangiopancreatography is recommended 5.