New Guidelines Provide a Clearer Path Forward for Abnormal Liver Tests

William F. Balistreri, MD


February 01, 2018

In This Article

The Patient With Abnormal Liver Chemistry Findings

The clinical assessment should begin with a thorough history, searching for risk factors for underlying liver disease; associated medical conditions; family history of liver disease; and use of alcohol or medications, including over-the-counter products and herbal supplements.

The physical examination should assess for stigmata of chronic liver disease, as well as signs or symptoms pointing to a specific liver disease. An initial screening test may help to establish whether liver function is impaired (coagulopathy or hypoalbuminemia).[4]

It is important to exclude other common conditions, such as diabetes, heart disease, celiac disease, and thyroid disease, which can cause or augment the liver chemistry abnormalities. Disorders of striated muscle, whether resulting from congenital or acquired muscle disorders or from muscle trauma or strenuous exercise, may lead to elevated AST/ALT levels, with predominant involvement of AST.[5] Screening for these disorders initially consists of assessment of creatine kinase and/or aldolase levels.

When the history and physical examination do not suggest a cause, the interpretation of abnormal liver chemistry tests requires a practical, algorithmic approach.

The Standard Approach

Clinicians generally apply one of two evaluative strategies: extensive testing for multiple potential causes at first pass, or focused testing for common diseases.[4,6]

The former approach is made easier by the widespread use of electronic medical records, in which providers may take advantage of tailored "order sets" that allow testing for all potential causes of an abnormal result. This deemphasizes the importance of a precise clinical history and a carefully conducted physical examination.[4] The focused approach is usually chosen on the basis of the likelihood of a specific disease given the history and physical examination.

The tradeoff of either approach involves the cost, number of office visits needed, and false-positive results generated.

Tapper and colleagues[6] simulated the evaluation of 10,000 adult outpatients with elevated ALT to compare these testing strategies. The extensive testing strategy cost the least and required the fewest doctor visits; however, the focused testing strategy generated fewer false-positives results and more biopsies.

This study shows that if no clues are available at the time of evaluation, extensive testing saves time and money while causing more false-positives.[6] However, if there are strong clues regarding the likelihood of a particular disease, focused testing saves time and money and prevents false-positives.


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