Day 4 - Elevated Liver Enzymes

Approach to Elevated Liver Enzymes

  1. Determine Pattern of Increased Liver Enzmyes

    • Hepatocellular: ALT/AST

    • Cholestatic: ALP/GGT

    • Mixed: AST/ALT/ALP/GGT

  2. Identify evidence of Liver Dysfunction

    • Low platelets, Low albumin, Elevated Bili, Elevated INR, PTT, Hypoglycemia

Approach based on pattern of liver enzyme elevation

Hepatocellular

  • Acute Viral Hepatitis: Hepatitis A, B, E

  • Alcohol induced

    • Different from acute alcoholic hepatitis as it represents inflammation without liver failure

    • AST/ALT > 2:1 ratio

  • Acute alcoholic hepatitis*

    • Associated with liver failure

    • Assess severity with Maddrey score

  • Drug induced

    • Statins, antibiotics, auto-immune agents, Tylenol

  • Fatty Liver

  • Ischemic Hepatitis

  • Congestive Hepatopathy

    • Seen in patients with CHF, right heart failure, severe TR, pulmonary hypertension

  • Wilson’s disease

  • Consider HELLP in pregnant patients

Thousands Club (AST/ALT >1000): Drug induced (ie: tylenol intoxication), Viral hepatitis, Ischemic Hepatitis (ie: shock liver), Autoimmune hepatitis

Work-Up:

  • Ultrasound of Liver with portal vein dopplers

  • Drug review

  • Tylenol level

  • Hepatitis A, B (sAg), E, CMV, EBV serology

Alcohol level

Mixed Pattern:

  • Drug Induced

  • NAFLD

Work-Up: Drug review, Ultrasound of Abdomen

Cholestatic

  • Cholelithiasis, choledocolethiasis

  • Malignancy:

    • Cholangiocarcinoma

    • Pancreatic Tumour

    • Lymphoma

  • Cholangitis

    • Charcot’s Triad: Fever, RUQ pain, Jaundice

    • Reynold’s Pentad: Fever, RUQ pain, aLOC, Jaundice, Hypotension

  • Autoimmune

    • PBC, PSC

  • Infiltrative

    • Sarcoidosis, Amyloidosis

Work-Up:

  • Ultrasound of liver, focusing on gallbladder, biliary and pancreatic pathology

  • Antibiotics if signs of Cholangitis

    • Cefazolin 2g IV q8h with Flagyl 500mg IV BID

  • GI consult/General surgery consult for cholelithiasis, choledocolithiasis, biliary stricture requiring cholecystectomy or biliary stent

Treatment:

  • Treat underlying cause

  • Monitor for signs of acute liver failure and treatment of complications (Ascites, hepatic encephalopathy, GI bleeds)

  • Gastroenterology consult especially for: any signs of acute liver failure, autoimmune diseases, Budd Chiari, Acute alcoholic hepatitis

The Intern at Work -