Evaluation of Abnormal Liver Chemistries Cheat Sheet (DRAFT) by [deleted]

These recomm­end­ations are intended for use by physicians and health care providers and suggest preferred approaches to the diagnoses and evaluation of those with abnormal liver tests.

These guidelines are intended to be flexible and should be adjusted as deemed approp­riate when applied to individual patients. Recomm­end­ations are eviden­ce-­based where possible. On subjects lacking rigid scientific data, recomm­end­ations are made based on the consensus opinion of the authors. To more fully charac­terize the available evidence reporting the recomm­end­ations, the ACG Practice Guideline Committee has adopted the classi­fic­ation used by the grading of recomm­end­ation assess­ment, develo­pment, and evaluation workup with modifi­cat­ions. Th e strength of recomm­end­ations are classified as strong or condit­ional. The quality of evidence supporting strong or weak recomm­end­ations are designated by the following level is high, Moderate low, or very low quality. This is a practice guideline rather than a review article.

1. Before initiation of evaluation of abnormal liver chemis­tries, one should repeat the lab panel and/or perform a clarifying test (e.g., GGT if serum alkaline phosphate is elevated) to confirm that the liver chemistry is actually abnormal. (Strong recomm­end­ation, very low level of evidence).
2. Testing for chronic hepatitis C is conducted with anti-HCV and confir­mation is performed with HCV-RNA by nucleic acid testing. Risk factors for hepatitis C include history of intranasal or intrav­enous drug use, tattoos, body piercings, blood transf­usions, high risk sexual conduct, and those born between 1945 and 1965. Testing for acute hepatitis C is with anti-HCV and HCV RNA by nucleic acid testing. (Strong recomm­end­ation, very low level of evidence).
3. Testing for chronic hepatitis B is conducted with HBsAg testing. Testing for acute hepatitis B is with HBsAg and IgM anti-HBc. The following groups are at highest risk: persons born in endemic or hypere­ndemic areas (HBsAg prevalence >2%), men who have sex with men, persons who have ever used injection drugs, dialysis patients, HIV-in­fected indivi­duals, pregnant women, and family members, household members, and sexual contacts of HBV-in­fected persons. (Strong recomm­end­ation, very low level of evidence).
4. Testing for acute Hepatitis A (IgM HAV) should occur in patients presenting with acute hepatitis and possible fecal-oral exposure. Testing for acute hepatitis E (IgM HEV) should also be considered in those returning from endemic areas and whose tests for acute hepatitis A, B, and C are negative. (Strong recomm­end­ation, very low level of evidence).
5. Patients with elevated BMI and other features of metabolic syndrome including diabetes mellitus, overweight or obesity, hyperl­ipi­demia, or hypert­ension with mild elevations of ALT should undergo screening for NAFLD with ultras­ound. (Strong recomm­end­ation, very low level of evidence).
6. Women consuming more than 140 g per week or men consuming more than 210 g per week who present with AST>ALT should be considered at risk for alcoholic liver disease and should be counseled for alcohol cessation. (Strong recomm­end­ation, very low level of evidence).
7. All patients with abnormal liver chemis­tries in the absence of acute hepatitis should undergo testing for hereditary hemoch­rom­atosis with an iron level, transf­errin satura­tion, and serum ferritin. HFE gene mutation analysis should be performed in patients with transf­errin saturation ≥45% and/or elevated serum ferritin. (Strong recomm­end­ation, very low level of evidence).
8. Patients with abnormal AST and ALT levels, partic­ularly patients with other autoimmune condit­ions, should undergo testing for autoimmune liver disease including ANA, ASMA, and globulin level. (Strong recomm­end­ation, very low level of evidence).
9. Patients with persis­tently elevated AST and ALT levels, especially patien­ts<55 years of age, should undergo screening for Wilson’s disease with serum cerulo­plasmin testing. In the setting of low cerulo­pla­smin, confir­matory testing with 24-h urinary copper and slit-lamp eye examin­ation to identify pathog­nomonic Kayser­–Fl­eischer rings should occur. (Strong recomm­end­ation, very low level of evidence).
10. Patients with persis­tently elevated AST or ALT should undergo screening for alpha-1 anti-t­rypsin (A1AT) defi ciency with alpha-1 anti-t­rypsin phenotype. (Strong recomm­end­ation, very low level of evidence).
11. Physicians should ask patients with abnormal liver chemis­tries about prescribed and over-t­he-­counter medica­tions, non-pr­esc­ribed comple­mentary or altern­ative medicines, and dietary or herbal supple­ments which may be associated with DILI. (Strong recomm­end­ation, very low level of evidence).
12. A liver biopsy may be considered when serologic testing and imaging fails to elucidate a diagnosis, to stage a condition, or when multiple diagnoses are possible. (Strong recomm­end­ation, very low level of evidence).
13. An elevation of alkaline phosph­atase should be confi rmed with an elevation in GGT. Given its lack of specifi city for liver disease, GGT should not be used as a screening test for underlying liver disease in the absence of other abnormal liver chemis­tries. (Strong recomm­end­ation, very low level of evidence).
14. Patients with alkaline phosph­atase elevation with or without elevation of bilirubin should undergo testing for PBC (formerly named primary biliary cirrhosis) with testing for anti-m­ito­cho­ndrial antibody. (Strong recomm­end­ation, very low level of evidence).
15. Patients with alkaline phosph­atase elevation with or without elevation of bilirubin should undergo testing for PSC with MR cholan­gio­graphy or ERCP in conjun­ction with IgG4. (Strong recomm­end­ation, very low level of evidence).
16. In those with ALT and/or AST levels <5X ULN, the history and laboratory testing should assess for viral hepatitis B and C, alcoholic and NAFLD, hemoch­rom­atosis, Wilson’s disease, alpha-­1-a­nti­-tr­ypsin defi ciency, autoimmune hepatitis and consider drugs/­sup­plement related injury. (Strong recomm­end­ation, very low level of evidence).
17. In those with ALT and/or AST levels 5–15X ULN, evaluation should also assess for acute hepatitis A, B, and C in addition to all etiologies for AST/ALT elevation less than 5x ULN. (strong recomm­end­ation, very low level of evidence).
18. In those with ALT and/or AST levels­>15X ULN, or massive elevation ALT of >10,000 IU/l, evaluation should also assess for acetam­inophen toxicity and ischemic hepato­pathy (shock liver). (Strong recomm­end­ation, very low level of evidence).
19. A patient presenting with acute hepatitis with an elevated prothr­ombin time, and/or enceph­alo­pathy requires immediate referral
to liver specia­list. (Strong recomm­end­ation, very low level of evidence)