What is the initial workup and management for an 18-year-old male with elevated Liver Function Tests (LFTs)?

Initial Workup and Management of Elevated Liver Function Tests in an 18-Year-Old Male

The initial workup for an 18-year-old male with elevated liver function tests (LFTs) should include a comprehensive liver etiology screen with abdominal ultrasound, viral hepatitis testing, autoimmune markers, and assessment of metabolic and lifestyle factors. 1

Step 1: Initial Assessment

History Focus Points:

• Alcohol consumption patterns
• Medication use (prescription, OTC, supplements)
• Recreational drug use
• Family history of liver disease
• Risk factors for viral hepatitis (IV drug use, sexual history)
• Symptoms (fatigue, abdominal pain, jaundice, pruritus)
• Dietary habits and weight changes

Physical Examination:

• BMI calculation
• Abdominal examination (hepatomegaly, splenomegaly)
• Signs of chronic liver disease (jaundice, spider angiomata, palmar erythema)
• Signs of metabolic syndrome

Step 2: First-Line Investigations

Laboratory Tests:

• Complete liver panel:
  • ALT, AST, GGT, ALP, bilirubin (total and direct)
  • Albumin, INR/PT (if elevated enzymes suggest significant disease)
  • Complete blood count with platelets
  • Fasting glucose, lipid profile

Liver Etiology Screen:

• Viral hepatitis serology:
  • Hepatitis B surface antigen
  • Hepatitis C antibody (with PCR follow-up if positive)
• Autoimmune markers:
  • Anti-mitochondrial antibody
  • Anti-smooth muscle antibody
  • Antinuclear antibody
• Iron studies:
  • Serum ferritin
  • Transferrin saturation
• Serum immunoglobulins
• Alpha-1-antitrypsin level
• Ceruloplasmin (if clinically indicated)

Imaging:

• Abdominal ultrasound (to assess liver echogenicity, size, biliary system)

Step 3: Risk Stratification and Management

For Suspected NAFLD:

1. Calculate FIB-4 score or NAFLD Fibrosis Score 1, 2
2. If FIB-4 <1.3: Low risk - manage in primary care
3. If FIB-4 1.3-3.25: Intermediate risk - consider second-line testing (ELF test or FibroScan)
4. If FIB-4 >3.25: High risk - refer to hepatology

For Suspected Alcohol-Related Liver Disease:

1. Assess alcohol consumption patterns
2. Consider AUDIT score (refer to alcohol services if score >19) 1
3. If harmful drinking identified, consider FibroScan/elastography
4. Refer to secondary care if evidence of advanced disease or FibroScan >16 kPa 1

For Suspected Drug-Induced Liver Injury:

1. Discontinue suspected hepatotoxic medications or supplements 2
2. Monitor LFTs after discontinuation
3. Consider rechallenge only under specialist supervision

Step 4: Management Based on Etiology

NAFLD Management:

• Lifestyle modifications:
  • Weight loss (3-5% to improve steatosis, 7-10% for inflammation) 2
  • Mediterranean diet pattern
  • 150-300 minutes/week moderate physical activity
  • Limit alcohol consumption

Alcohol-Related Liver Disease:

• Complete abstinence from alcohol 1, 2
• Referral to alcohol support services
• Monitor for withdrawal symptoms if heavy drinker

Viral Hepatitis:

• Refer to specialist for antiviral therapy consideration 2
• Vaccination for hepatitis A and B if not immune

Autoimmune Hepatitis:

• Refer to specialist for immunosuppressive therapy consideration 2

Follow-up Recommendations

Monitoring:

• Repeat LFTs every 3-6 months initially 2
• Lipid profile and glucose/HbA1c every 6 months for NAFLD 2
• Repeat fibrosis assessment every 2-3 years for low-risk patients 2

Indications for Immediate Specialist Referral:

• AST/ALT >5x upper limit of normal
• Evidence of advanced fibrosis
• Clinical jaundice
• Failed response to initial management after 6 months
• Suspected hepatic or biliary malignancy

Common Pitfalls to Avoid

1. Assuming mildly elevated enzymes are benign without proper evaluation - even mild elevations warrant investigation 2

2. Focusing only on liver enzymes without addressing metabolic risk factors - the extent of LFT abnormality is not necessarily a guide to clinical significance 1

3. Failing to screen for other chronic liver diseases that may coexist with NAFLD 2

4. Recommending rapid weight loss (>1 kg/week) which can worsen portal inflammation and fibrosis 2

5. Ignoring transient elevations - 75% of untreated abnormal LFTs remain abnormal at 2 years if the underlying cause is not addressed 2