What is the significance of elevated Aspartate Aminotransferase (AST) and Alanine Aminotransferase (ALT) levels in a patient with left upper quadrant (LUQ) abdominal pain?

From the Guidelines

For a patient with left upper quadrant (LUQ) pain and elevated liver enzymes (AST 116, ALT 72), I strongly recommend a comprehensive evaluation focusing on both hepatic and splenic causes, as the most recent and highest quality study suggests that hepatocellular injury is a significant concern in such cases 1. The patient's elevated liver enzymes, with an AST:ALT ratio of approximately 1.6:1, may indicate alcoholic liver disease, but other causes such as viral hepatitis, medication toxicity, or non-alcoholic fatty liver disease should also be considered. Some key points to consider in the evaluation and management of this patient include:

• Initial management should include complete blood count, comprehensive metabolic panel, lipase, and abdominal imaging (ultrasound or CT scan) to assess for potential causes of LUQ pain and elevated liver enzymes.
• The patient should temporarily avoid alcohol and hepatotoxic medications while awaiting diagnosis, as these can exacerbate liver injury.
• The LUQ pain could indicate splenic involvement (such as splenomegaly, infarction, or rupture), pancreatic disease, or referred pain from liver pathology, and imaging studies can help to differentiate between these possibilities.
• Patients with these findings may have underlying cirrhosis, so assessment for complications like varices or ascites is warranted, as noted in the study on acute nonlocalized abdominal pain 1.
• Prompt referral to gastroenterology is appropriate if the patient shows signs of acute liver injury, has persistent symptoms, or if initial workup is inconclusive, as suggested by the guidelines for detection, assessment, and management of suspected acute drug-induced liver injury 1.
• Hydration and pain management with acetaminophen (up to 2g/day) can be provided while avoiding NSAIDs due to potential gastric irritation, as recommended in the study on abnormal liver function tests 1.

From the Research

Liver Enzyme Levels and LUQ Pain

The patient's liver enzyme levels are AST 116 and ALT 72, which indicate hepatocellular injury 2.

• The degree of elevation of ALT and AST helps guide the evaluation of hepatocellular injury.
• A true healthy normal ALT level ranges from 19 to 25 IU/l for females and 29 to 33 IU/l for males 2.
• The patient's ALT level is elevated, which has been associated with increased liver-related mortality 2.

Possible Causes of Elevated Liver Enzymes

The evaluation of hepatocellular injury includes testing for:

• Viral hepatitis A, B, and C 2
• Nonalcoholic fatty liver disease and alcoholic liver disease 2
• Hereditary hemochromatosis, autoimmune hepatitis, Wilson's disease, and alpha-1 antitrypsin deficiency 2
• A history of prescribed and over-the-counter medicines should be sought 2

Relation to Hepatitis

A study on chronic hepatitis B and C patients found that MMP-9 levels were significantly higher in HCV than in HBV patients and positively correlated with HBV viral load and AST:ALT ratio 3.

• The AST:ALT ratio in the patient is approximately 1.6, which may be relevant in the context of hepatitis 3.
• However, the study suggests that the pathological mechanism of HCV and HBV may be different, and HCV may promote hepatocyte damage and fibrosis through mechanisms other than replication 3.