title: ACG Clinical Guideline: Evaluation of Abnormal Liver Chemistries.
abstract: Clinicians are required to assess abnormal liver chemistries on a daily basis. The most common liver chemistries ordered are serum alanine aminotransferase (ALT), aspartate aminotransferase (AST), alkaline phosphatase and bilirubin. These tests should be termed liver chemistries or liver tests. Hepatocellular injury is defined as disproportionate elevation of AST and ALT levels compared with alkaline phosphatase levels. Cholestatic injury is defined as disproportionate elevation of alkaline phosphatase level as compared with AST and ALT levels. The majority of bilirubin circulates as unconjugated bilirubin and an elevated conjugated bilirubin implies hepatocellular disease or cholestasis. Multiple studies have demonstrated that the presence of an elevated ALT has been associated with increased liver-related mortality. A true healthy normal ALT level ranges from 29 to 33 IU/l for males, 19 to 25 IU/l for females and levels above this should be assessed. The degree of elevation of ALT and or AST in the clinical setting helps guide the evaluation. The evaluation of hepatocellular injury includes testing for viral hepatitis A, B, and C, assessment for nonalcoholic fatty liver disease and alcoholic liver disease, screening for hereditary hemochromatosis, autoimmune hepatitis, Wilson's disease, and alpha-1 antitrypsin deficiency. In addition, a history of prescribed and over-the-counter medicines should be sought. For the evaluation of an alkaline phosphatase elevation determined to be of hepatic origin, testing for primary biliary cholangitis and primary sclerosing cholangitis should be undertaken. Total bilirubin elevation can occur in either cholestatic or hepatocellular diseases. Elevated total serum bilirubin levels should be fractionated to direct and indirect bilirubin fractions and an elevated serum conjugated bilirubin implies hepatocellular disease or biliary obstruction in most settings. 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.
authors.affiliation: Division of Gastroenterology/Hepatology, Department of Medicine, Stanford University School of Medicine, Palo Alto, California, USA.
authors.forename: Paul Y
authors.initials: PY
authors.lastname: Kwo
authors.affiliation: Digestive Health Institute, University Hospitals Cleveland Medical Center and Division of Gastroenterology and Liver Disease, Department of Medicine, Case Western Reserve University School of Medicine, Cleveland, Ohio, USA.
authors.forename: Stanley M
authors.initials: SM
authors.lastname: Cohen
authors.affiliation: Yale Viral Hepatitis Program, Yale University School of Medicine, New Haven, Connecticut, USA.
authors.forename: Joseph K
authors.initials: JK
authors.lastname: Lim
mesh_terms: D000410:Alanine Transaminase / Q000097:blood*; D000469:Alkaline Phosphatase / Q000097:blood*; D001219:Aspartate Aminotransferases / Q000097:blood*; D001663:Bilirubin / Q000097:blood*; D001706:Biopsy; D056486:Chemical and Drug Induced Liver Injury / Q000097:blood / Q000175:diagnosis / Q000473:pathology; D002779:Cholestasis / Q000097:blood / Q000175:diagnosis* / Q000473:pathology; D006432:Hemochromatosis / Q000097:blood / Q000175:diagnosis / Q000473:pathology; D019693:Hepatitis, Autoimmune / Q000097:blood / Q000175:diagnosis / Q000473:pathology; D006525:Hepatitis, Viral, Human / Q000097:blood / Q000175:diagnosis / Q000473:pathology; D006527:Hepatolenticular Degeneration / Q000097:blood / Q000175:diagnosis / Q000473:pathology; D006801:Humans; D008099:Liver / Q000378:metabolism / Q000473:pathology; D008107:Liver Diseases / Q000097:blood / Q000175:diagnosis* / Q000473:pathology; D008108:Liver Diseases, Alcoholic / Q000097:blood / Q000175:diagnosis / Q000473:pathology; D065626:Non-alcoholic Fatty Liver Disease / Q000097:blood / Q000175:diagnosis / Q000473:pathology; D019896:alpha 1-Antitrypsin Deficiency / Q000097:blood / Q000175:diagnosis / Q000473:pathology
chemical_list: D001219:Aspartate Aminotransferases; D000410:Alanine Transaminase; D000469:Alkaline Phosphatase; D001663:Bilirubin