From the Guidelines
The pattern observed with ALK (alkaline phosphatase) at 179 and ALT (alanine aminotransferase) at 242 suggests a hepatocellular pattern of liver injury, as indicated by the ALT/AP ratio of 1.35, which is less than 2, but given the context, it is more aligned with a hepatocellular injury pattern due to the higher ALT value compared to ALK 1.
Key Points to Consider
- The ALT level of 242 is moderately elevated, while the ALK at 179 is only mildly elevated, suggesting active inflammation of liver cells rather than cholestasis.
- This pattern is commonly seen in conditions such as viral hepatitis, drug-induced liver injury, alcoholic hepatitis, or nonalcoholic fatty liver disease.
- According to the guidelines on the management of abnormal liver blood tests 2, initial investigation for potential liver disease should include bilirubin, albumin, ALT, ALP, and γ-glutamyltransferase (GGT), together with a full blood count if not already performed within the previous 12 months.
Recommendations for Further Evaluation
- Additional liver function tests, hepatitis serologies, and possibly imaging studies should be conducted to determine the specific cause of this hepatocellular pattern of liver injury.
- A liver aetiology screen should be considered, including abdominal ultrasound scan, hepatitis B surface antigen, hepatitis C antibody, anti-mitochondrial antibody, anti-smooth muscle antibody, antinuclear antibody, serum immunoglobulins, simultaneous serum ferritin, and transferrin saturation 2.
- Risk stratification to determine the extent of liver fibrosis should be performed in adults with nonalcoholic fatty liver disease (NAFLD) using either fibrosis-4 (FIB-4) or NAFLD Fibrosis Score (NFS) 2.
From the Research
Pattern Identification
To identify the pattern of liver enzyme elevation, we need to analyze the given values: Alk 179, Alt 242.
- The alkaline phosphatase (Alk) level is 179, which is elevated.
- The alanine aminotransferase (Alt) level is 242, which is also elevated.
Hepatocellular vs Cholestatic Pattern
According to the study 3, hepatocellular injury is defined as disproportionate elevation of AST and ALT levels compared with alkaline phosphatase levels.
- In this case, the Alt level is elevated, which could indicate hepatocellular injury.
- However, the Alk level is also elevated, which could suggest a cholestatic pattern.
Further Evaluation
The study 4 suggests that a hepatic enzyme pattern (predominant transaminase elevation) should be discriminated from a cholestatic pattern (predominant AP and G-GT elevation).
- To determine the underlying cause of the elevated liver enzymes, further evaluation is necessary, including testing for viral hepatitis, non-alcoholic fatty liver disease, alcoholic liver disease, and autoimmune hepatitis, as recommended by the study 3.
- The study 5 emphasizes the importance of interpreting liver function tests correctly and considering other biochemical parameters, such as albumin, INR, and platelet count.
Autoimmune Liver Disease
The study 6 highlights the importance of considering autoimmune liver diseases, such as autoimmune hepatitis, primary biliary cirrhosis, and primary sclerosing cholangitis, in the differential diagnosis of elevated liver function tests.
- The study 7 suggests that testing for liver-related autoantibodies should be included in the workup of patients with hepatitis or cholestasis of unknown origin.