Liver Enzyme Elevation (Incidental) Referral Guideline
Diagnosis/Definition
Elevation of serum ALT or AST in a patient for > 6 months. Cases with ALT > 150, or suspected autoimmune disease, should be sent sooner than 6 months (see below).
Initial Diagnosis and Management
Usually an incidental finding in a chemistry panel obtained for reasons other than suspected liver disease.
Review medication list (prescription, over-the-counter, and supplements) and discontinue, if possible, medications that are known to cause abnormal liver enzymes.
Have patient abstain from alcohol (suspect alcohol when AST > ALT and GGT elevated).
If patient is overweight, encourage weight loss.
Ongoing Management and Objectives
Repeat liver enzymes in one month, and if still abnormal, following lab tests are recommended:
HBsAg, HCV Ab, ANA, ASMA, Iron & TIBC (fasting), Ceruloplasmin (if < age 40), Alpha-1-antrypsin level, SPEP, Protime, and U/S RUQ (include AMA if alkaline phosphatase elevated). For ALT <150, above studies can be obtained gradually over 6 months while observing the enzymes for possible spontaneous resolution. Check common things first (like viral studies and fasting iron panel). If ALT > 150, check above studies and referral should be within 2 months if enzymes are not resolving (or refer immediately if autoimmune hepatitis is suspected - young female, other autoimmune features, elevated gamma globulin, or + ANA or ASMA).
For minor elevations (<1.5x normal ALT) if work-up is negative and ultrasound suggests fatty liver, referral may not be necessary and a trial of weight loss is reasonable. Indications for Specialty Care Referral If any of the above listed diagnostic tests are abnormal. If AST or ALT is above normal for 6 months or more and above work-up is complete (see also "minor elevations" above). If AST or ALT is > 150 and not coming down for 2 or more months and above work-up is complete (or pending).
Signs or symptoms suggestive of underlying liver disease (RUQ pain, tenderness, encephalopathy, ascites).
If autoimmune hepatitis is suspected (see above).
Criteria for Return to Primary Care
Completion of GI evaluation with assessment of potential etiology, severity, prognosis, treatment plan (if any), and recommendations for any periodic surveillance or evaluation.
Certain disease categories treatment plans may require ongoing close follow-up with the gastroenterologist (ie., interferon for viral hepatitis).
For information on Shwachman-Diamond Syndrome check out Shwachman-Diamond America
