What is the appropriate management for a 13-year-old patient presenting with vomiting, loose stools, elevated SGOT (Serum Glutamic-Oxaloacetic Transaminase), decreased serum albumin, and changes in serum bilirubin levels?

Management of a 13-Year-Old with Vomiting, Diarrhea, and Mild Transaminase Elevation

This patient requires supportive care with oral rehydration therapy and nutritional management, as the laboratory findings indicate mild, self-limited gastroenteritis without significant hepatic dysfunction or alarm features requiring specific intervention.

Clinical Assessment

The laboratory values reveal:

• Mildly elevated SGOT (AST): 44 U/L (previously 40 U/L) - minimally elevated
• Normal serum albumin: 3.8 g/dL (previously 4.0 g/dL) - within normal range
• Normal bilirubin: 1.0 mg/dL (previously 1.7 mg/dL) - improving and within normal limits

These findings indicate no significant hepatic dysfunction. The serum albumin remains normal (>3.0 g/dL), which excludes chronic liver disease or severe acute hepatic injury 1. The improving bilirubin trend and stable, minimally elevated transaminases suggest a self-limited process, most consistent with viral gastroenteritis with minor hepatic involvement 2.

Immediate Management: Rehydration

Assess dehydration severity by examining skin turgor, mucous membranes, mental status, pulse, and capillary refill time 3:

• Mild dehydration (3-5% fluid deficit): Administer 50 ml/kg of oral rehydration solution (ORS) over 2-4 hours 3
• Moderate dehydration (6-9% fluid deficit): Administer 100 ml/kg of ORS over 2-4 hours 3
• Severe dehydration (≥10% fluid deficit): Immediate intravenous rehydration with isotonic fluids until pulse, perfusion, and mental status normalize, then transition to oral rehydration 3

For ongoing losses: Replace with 10 ml/kg of ORS for each watery stool and 2 ml/kg of ORS for each vomiting episode 4, 3.

If vomiting is present, administer small volumes of ORS (5-10 mL) every 1-2 minutes with gradual increase, using a spoon or syringe 3. Avoid allowing the child to drink large volumes rapidly, as this worsens vomiting 3.

Nutritional Management

• Resume age-appropriate diet during or immediately after rehydration is completed 3
• Include starches, cereals, yogurt, fruits, and vegetables; avoid foods high in simple sugars and fats 4, 3
• Continue normal eating patterns - there is no need for dietary restriction given normal albumin and improving bilirubin 4

Laboratory Monitoring

No additional liver function testing is required at this time given:

• Normal albumin excludes significant hepatic synthetic dysfunction 1
• Improving bilirubin trend (1.7 → 1.0 mg/dL) indicates resolution 1
• Mildly elevated SGOT (40-44 U/L) is non-specific and commonly seen in viral gastroenteritis 2

Reassess hydration status after 2-4 hours of rehydration therapy 4, 3.

When to Investigate Further

Consider additional evaluation only if:

• Persistent elevation of liver enzymes beyond 12 months or decline in serum albumin below normal range in a patient with normal nutritional status 1
• Alarm features develop: fever, weight loss, blood in stools, anemia, or abnormal physical findings 1
• Bloody diarrhea (dysentery) appears, which may require antimicrobial treatment 3
• High stool output (>10 mL/kg/hour) or intractable vomiting preventing oral rehydration 3

Adjunctive Therapies

• Zinc supplementation (10-20 mg daily for 10-14 days) reduces diarrhea duration, particularly if signs of malnutrition are present 4, 3
• Probiotics may reduce symptom severity and duration in immunocompetent children 4, 3
• Antibiotics are NOT indicated unless dysentery is present, high fever occurs, watery diarrhea persists >5 days, or stool cultures identify a treatable pathogen 4, 3

Common Pitfalls to Avoid

• Do not order extensive hepatic workup for minimally elevated transaminases in the setting of acute gastroenteritis with normal albumin and improving bilirubin 1, 2
• Do not restrict diet unnecessarily - resume normal age-appropriate foods immediately after rehydration 4, 3
• Do not use antimotility drugs (loperamide) - these are absolutely contraindicated in all children <18 years of age 3
• Do not allow ad libitum drinking of large volumes of ORS in a vomiting child - this worsens symptoms 3