Differential Diagnosis for Mild Elevation in ALT and AST with ALT:AST 2:1

Single Most Likely Diagnosis

• Non-Alcoholic Fatty Liver Disease (NAFLD): This condition is the most common cause of mild elevations in liver enzymes, particularly with an ALT:AST ratio of 2:1, which is often seen in NAFLD due to the predominance of ALT elevation in this condition.

Other Likely Diagnoses

• Alcoholic Liver Disease: Although the ALT:AST ratio in alcoholic liver disease is typically less than 2:1, early stages or mild cases might present with a ratio close to 2:1, especially if the patient has not been consuming large amounts of alcohol.
• Viral Hepatitis: Acute or chronic viral hepatitis (e.g., hepatitis A, B, or C) can cause elevations in liver enzymes. The ALT:AST ratio can vary but often is greater than 1, making it a plausible diagnosis for a ratio of 2:1.
• Medication-Induced Liver Injury: Various medications can cause liver enzyme elevations, and the pattern can mimic that of NAFLD or other liver conditions, depending on the drug and individual response.

Do Not Miss Diagnoses

• Wilson's Disease: An inherited disorder that leads to copper accumulation in the liver. It can present with liver enzyme elevations and is critical to diagnose early to prevent liver damage and other complications.
• Autoimmune Hepatitis: A condition where the body's immune system attacks liver cells, leading to inflammation and liver damage. Early diagnosis and treatment are crucial to prevent progression to cirrhosis.
• Alpha-1 Antitrypsin Deficiency: A genetic disorder that may cause liver disease and lung disease. It's essential to identify this condition to provide appropriate management and genetic counseling.

Rare Diagnoses

• Hemochromatosis: A genetic disorder characterized by excessive iron accumulation in the body, leading to liver damage among other issues. It's less common than NAFLD but important to consider due to its potential for significant morbidity if untreated.
• Glycogen Storage Diseases: A group of inherited disorders that result from defects in enzymes involved in glycogen synthesis or breakdown, leading to accumulation of abnormal amounts or types of glycogen in liver cells.
• Budd-Chiari Syndrome: A rare condition caused by occlusion of the hepatic veins or the inferior vena cava, leading to liver enlargement, ascites, and liver dysfunction. It might present with elevated liver enzymes, although the pattern can vary.