What is the next step for a patient with elevated liver enzymes?

Management of Elevated Liver Enzymes: AST 200s and ALT 100s

For a 36-year-old male with AST in the 200s and ALT in the 100s on repeat labs, the next step should be a systematic diagnostic workup to determine the underlying cause, including comprehensive laboratory testing, abdominal ultrasound, and discontinuation of any potentially hepatotoxic medications. 1, 2

Pattern Recognition and Initial Assessment

• This presentation shows a hepatocellular pattern of injury with AST>ALT (AST:ALT ratio >2), which can suggest alcoholic liver disease, but requires further investigation 1, 3
• The elevation is moderate (AST 3-5× ULN) to severe (>5× ULN), requiring prompt evaluation 2, 3
• This pattern requires a systematic approach to identify the underlying cause and guide appropriate management 1

Initial Laboratory Testing

• Complete the liver function panel: alkaline phosphatase, GGT, total and direct bilirubin, albumin, and INR to assess liver synthetic function 1, 2
• Order complete blood count with platelets to evaluate for signs of portal hypertension 1
• Screen for viral hepatitis: Hepatitis B surface antigen, Hepatitis C antibody 1, 3
• Consider autoimmune markers: IgG, ANA, anti-smooth muscle antibody 1
• Obtain iron studies: serum iron, total iron-binding capacity, ferritin to rule out hemochromatosis 1
• Check fasting lipid profile and glucose to assess for metabolic syndrome 3

Imaging

• Perform abdominal ultrasound to assess liver parenchyma, rule out biliary obstruction, and look for signs of cirrhosis or focal lesions 1, 2
• Consider more advanced imaging based on initial ultrasound findings 1

Additional Targeted History

• Conduct detailed medication review including prescription medications, over-the-counter drugs, supplements, and herbal products 1, 2
• Assess alcohol consumption history (quantity, frequency, duration) 1, 3
• Identify risk factors for viral hepatitis (injection drug use, high-risk sexual behavior, etc.) 1
• Document family history of liver disease 1

Management Based on Severity

• For AST in the 200s (>5× ULN), immediately discontinue any potentially hepatotoxic medications 2, 3
• Repeat liver enzymes within 3-5 days to establish trend 1, 2
• If alcohol use is suspected, recommend complete abstinence 3
• If non-alcoholic fatty liver disease is suspected, recommend lifestyle modifications including weight loss and increased physical activity 3

Referral Criteria

• If ALT/AST remains >3× ULN after 3 months despite addressing modifiable factors 1
• If there is evidence of synthetic dysfunction (elevated INR, low albumin) 1, 2
• If imaging suggests advanced fibrosis, cirrhosis, or focal lesions 1
• If ALT >3× ULN with total bilirubin >2× ULN (meets Hy's Law criteria) 1, 2

Common Pitfalls to Avoid

• Don't simply repeat the same panel of tests without a diagnostic plan 1
• Don't ignore mild elevations, as 84% remain abnormal on retesting after 1 month 1
• Avoid premature discontinuation of all medications before identifying the likely causative agent 1
• Don't overlook alcohol use as a potential cause, especially with AST>ALT ratio 3
• Don't miss hepatitis B or C infection, which may be asymptomatic but require treatment 1, 2