-Definition: Mildly elevated liver transaminase levels are defined as levels that are less than 5 times the upper limit of normal.
-History and physical performed.
-DDx of elevated liver transaminases reviewed.
-A repeat CMP in 2-4 weeks done and reviewed, still elevated.
Initial testing. Will get:
–Fasting lipid profile (to evaluate for metabolic syndrome or nonalcoholic fatty liver).
-HBsAg, HCAb (to r/o chronic hepatitis)
-iron studies (serum iron, ferritin, and TIBC) to screen for hemochromatosis
–CMP (glucose),
–Lifestyle modification: If test results are normal, will do a trial of lifestyle modification with observation or further testing for less common causes is appropriate.
-Additional testing may include ultrasonography; measurement of α1-antitrypsin and ceruloplasmin; serum protein electrophoresis; and antinuclear antibody, smooth muscle antibody, and liver/kidney microsomal antibody type 1 testing.
-Referral: Will refer for further evaluation and possible liver biopsy if transaminase levels remain elevated for six months or more.
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AST/ALT ratio greater than 2 suggests alcoholic liver disease,
AST/ALT ratio of < 1 is associated with nonalcoholic fatty liver disease.
AST/ALT ratio > 4 may suggest Wilson disease.
References
Am Fam Physician. 2011 Nov 1;84(9):1003-1008. http://www.aafp.org/afp/2011/1101/p1003.html