What is the best course of action for a 22-year-old female with lower abdominal pain, elevated liver enzymes (aspartate aminotransferase (AST) and alanine aminotransferase (ALT) of 55), alkaline phosphatase (alk phos) of 127, and hyperbilirubinemia (total bilirubin of 2.4), with no known past medical history?

Evaluation and Management of a 22-Year-Old Female with Lower Abdominal Pain and Abnormal Liver Tests

Immediate Clinical Assessment

This patient requires urgent evaluation for pregnancy-related liver disease, particularly HELLP syndrome or acute fatty liver of pregnancy (AFLP), given her age, sex, and presentation with abdominal pain and elevated bilirubin. 1

Critical First Steps

• Obtain a pregnancy test immediately - this is the single most important initial test in any woman of reproductive age presenting with abdominal pain and liver abnormalities 1
• Assess for preeclampsia features including blood pressure, proteinuria, and symptoms of headache, visual changes, or right upper quadrant pain 1
• Order complete blood count with platelet count - thrombocytopenia (<150 × 10⁹/L) combined with elevated liver enzymes defines HELLP syndrome 1

Pattern Recognition

The laboratory pattern shows:

• Mixed hepatocellular-cholestatic injury with AST/ALT ratio of 1.0 (both at 55 U/L) and alkaline phosphatase of 127 U/L 1, 2
• Mild hyperbilirubinemia at 2.4 mg/dL suggests conjugated hyperbilirubinemia requiring further fractionation 3
• R value calculation: (55/40)/(127/120) = 1.3, indicating a cholestatic pattern (R ≤2) 1

Pregnancy-Specific Considerations

If Pregnancy Test is Positive

HELLP syndrome must be excluded immediately as it affects 0.2-0.6% of pregnancies and can rapidly progress to maternal organ failure 1:

• Platelets typically range from 50-150 × 10⁹/L 1
• AST and ALT are usually 2-30 times upper limit of normal 1
• Bilirubin is typically <5 mg/dL 1
• Patients commonly present with abdominal pain and nausea/vomiting 1

Acute fatty liver of pregnancy (AFLP) is less common (0.005-0.010%) but more severe 1:

• AST and ALT typically 300-1,000 U/L (higher than this patient) 1
• Associated with hypoglycemia, elevated PT, low fibrinogen 1
• Requires immediate delivery 1

Intrahepatic cholestasis of pregnancy (ICP) should be considered 1:

• Presents with generalized pruritus, especially palms and soles 1
• AST and ALT 2-30 times upper limit of normal 1
• Total bile acids >10 μmol/L are diagnostic 1

If Pregnancy Test is Negative

Non-Pregnancy Differential Diagnosis

Immediate Workup Required

Obtain hepatitis serologies (hepatitis A IgM, hepatitis B surface antigen and core antibody, hepatitis C antibody) as viral hepatitis is a common cause of this presentation in young adults 3, 4

Perform right upper quadrant ultrasound to evaluate for:

• Biliary obstruction (sensitivity 65-95% for hepatobiliary pathology) 3
• Fatty liver disease 1
• Hepatic masses or abscesses 1

Additional laboratory tests to order simultaneously 3, 4:

• Direct and indirect bilirubin fractionation 3
• Autoimmune markers (ANA, anti-smooth muscle antibody) - autoimmune hepatitis can present in young women 3, 5
• Ceruloplasmin and serum copper - Wilson disease must be excluded in any patient under 40 with unexplained liver disease 6
• Acetaminophen level and comprehensive drug/supplement history 4
• Alcohol use assessment 1

Wilson Disease Screening Priority

In a 22-year-old with elevated liver enzymes, Wilson disease screening is mandatory 6:

• Measure ceruloplasmin by oxidase method (more specific than nephelometry) 6
• Serum copper levels >200 μg/dL suggest Wilson disease 6
• AST:ALT ratio >2.2 in acute Wilson disease has 94% sensitivity 6
• This patient's AST:ALT ratio of 1.0 makes acute Wilson disease less likely but does not exclude chronic Wilson disease 6

Clinical Decision-Making Algorithm

Hospitalization Criteria

This patient likely requires hospital admission based on 7:

• Combination of abdominal pain, elevated liver enzymes, and hyperbilirubinemia 7
• Need for serial liver function tests to monitor for progression 7
• Elevated bilirubin (2.4 mg/dL) with transaminitis suggests more severe injury requiring close monitoring 7

Outpatient Management Acceptable If:

• Pregnancy definitively excluded 1
• Patient is clinically stable without signs of acute liver failure 4
• No evidence of coagulopathy or encephalopathy 1
• Reliable follow-up within 24-48 hours can be ensured 8
• Serial laboratory monitoring can be arranged 7

Common Pitfalls to Avoid

Do not assume this is simple fatty liver disease - while NAFLD is common, the combination of symptoms, elevated bilirubin, and young age requires exclusion of more serious etiologies first 1, 4

Do not order "extensive testing" without clinical context - focused testing based on pre-test probability is more cost-effective and generates fewer false positives 8

Do not miss drug-induced liver injury - obtain detailed history of all medications, supplements, and herbal products, as this is a common and reversible cause 3, 4

Do not delay imaging - ultrasound should be performed urgently to exclude biliary obstruction, which requires different management 3, 2