From the Guidelines
The workup for asymptomatic transaminitis with a total bilirubin of 2.12 should begin with a comprehensive history and physical examination, followed by laboratory and imaging studies to determine the underlying cause, as recommended by the most recent guidelines 1. The initial step in evaluating asymptomatic transaminitis is to determine the severity of the liver enzyme elevations and to assess for any signs of liver dysfunction.
- Initial laboratory tests should include a complete liver panel (ALT, AST, alkaline phosphatase, GGT), direct and indirect bilirubin fractions, complete blood count, coagulation studies (PT/INR), and albumin level.
- Additional testing should include viral hepatitis serologies (hepatitis A, B, C), autoimmune markers (ANA, anti-smooth muscle antibody, anti-mitochondrial antibody), iron studies, ceruloplasmin level (for Wilson's disease), alpha-1 antitrypsin level, and screening for alcohol use, as suggested by previous guidelines 1. An abdominal ultrasound should be performed to evaluate liver structure, biliary tract, and rule out obstruction, as it is a non-invasive and effective initial imaging study. If these initial tests are inconclusive, further evaluation may include magnetic resonance cholangiopancreatography (MRCP) or endoscopic retrograde cholangiopancreatography (ERCP) for biliary evaluation, or a liver biopsy for definitive diagnosis, as recommended by the guidelines 1. This systematic approach is necessary because asymptomatic transaminitis with mild hyperbilirubinemia can result from various conditions including viral hepatitis, medication effects, alcohol use, autoimmune hepatitis, non-alcoholic fatty liver disease, or early stages of more serious liver diseases, and proper identification of the cause is essential for appropriate management.
- The most recent guidelines 1 emphasize the importance of a comprehensive evaluation to determine the underlying cause of asymptomatic transaminitis and to guide further management.
- Previous studies 1 have also highlighted the need for a thorough evaluation, including laboratory and imaging studies, to determine the cause of abnormal liver function tests.
From the Research
Asymptomatic Transaminitis and Total Bilirubin of 2.12
- The patient's condition involves asymptomatic transaminitis, which refers to elevated liver enzymes without noticeable symptoms, and a total bilirubin level of 2.12 2.
- The initial step in evaluating a patient with jaundice or elevated bilirubin levels is to conduct a careful history and physical examination, followed by imaging assessment of the biliary tree and liver 3.
- For asymptomatic patients with mildly elevated liver transaminase levels, the diagnostic workup should start with a stepwise evaluation based on the prevalence of diseases that cause mild elevations in transaminase levels 4, 5.
- Common causes of elevated transaminase levels include nonalcoholic fatty liver disease, alcoholic liver disease, medication-associated liver injury, viral hepatitis, and hemochromatosis 4, 5.
- Initial testing should include a fasting lipid profile, measurement of glucose, serum iron, and ferritin, total iron-binding capacity, and hepatitis B surface antigen and hepatitis C virus antibody testing 4, 5.
- If test results are normal, a trial of lifestyle modification with observation or further testing for less common causes is appropriate 4, 5.
- Additional testing may include ultrasonography, measurement of α(1)-antitrypsin and ceruloplasmin, serum protein electrophoresis, and antinuclear antibody, smooth muscle antibody, and liver/kidney microsomal antibody type 1 testing 4.
- Referral for further evaluation and possible liver biopsy is recommended if transaminase levels remain elevated for six months or more 4.