Elevated liver Enzyme
ALP >> AST/ALT → Cholestatic
AST/ALT >> ALP → Hepatocellular/Transaminitis
Both clearly up → Mixed

DDX - AST/ALT

  • severe >1000

    • Acute viral hepatitis (A, B, C, D, E), jaundice, RUQ pain, N/V, Hep panel (HAV IgM, HBsAg, anti-HBc, HCV Ab)

    • Ischemia (“shock liver”)- septic,(lactate, echo )

    • Toxins (esp. Acetaminophen) HX, acetaminophen level

  • Mod (200–1000)

    • Viral hepatitis (hepatitis panel (HAV IgM, HBsAg, anti-HBc, HCV Ab)

    • Alcohol AST:ALT >2:1

    • Autoimmune IgG, ANA/SMA positive

    • Drug-induced (APAP, abx, NSAIDs) med review + stop offending

    • Cirrhosis of any etiology, ↑ INR, ↓ albumin, RUQ US

  • Mild (<200)

    • MASLD/NAFLD) ALT > AST, MC , Obesity T2D , HLD , HTN

    • Alcohol-associated AST:ALT >2:1 clinical dx ± RUQ US,

    • medication induced (statins, abx, APAP)

    • Chronic meds

  • CHOLESTATIC (ALP (>250) >> AST/ALT)

    • Biliary obstruction (stone, tumor) jaundice, RUQ pain, RUQ us

    • Cholangitis, fever + RUQ pain + jaundice (Charcot triad),RUQ us-> ERCP

    • Primary sclerosing cholangitis (PSC) (Inflammation + fibrosis of bile ducts (intra + extrahepatic), IBD Hx, younger men, + MRCP-> “beading”

    • Primary Biliary Cholangitis (PBC) (Autoimmune) , Middle-aged woman, + antimitochondrial antibody (AMA)

  • MIXED PATTERN (AST/ALT + ALP)

    • Drug-induced , new meds stop offending agent

    • septic

  • ↑ CK → muscle, not liver