ORLANDO, FLA. — Isolated cases of abnormal liver function tests are a common finding in family medicine. Daniel J. Tambunan, M.D., shared three rules for dealing with elevated liver enzymes at the annual meeting of the American Academy of Family Physicians.
“You could go to the extreme and order a million-dollar work-up, but I am trying to propose something more user-friendly and a much a more efficient way to find out what is causing the elevated liver enzymes,” said Dr. Tambunan, assistant director of the Florida Hospital Family Practice Residency program in Orlando.
First, he recommends inquiring about alcohol (60% to 70% of abnormal results are secondary to alcohol use), prescribed medications, (including antibiotics and anticonvulsants), and over-the-counter medications, such as acetaminophen, or herbal remedies (especially Kava).
Second, if the level is less than two times the upper limit of normal, recheck the liver enzymes in 6–8 weeks and advise the patient not to drink alcohol. If the enzymes remain elevated, complete the work-up.
Third, if the initial enzyme levels are more than two times the upper limit of normal, do a work-up; initial tests for elevated AST/ALT should include a hepatitis B and C panel (ALT levels will wax and wane in hepatitis C), iron and total iron-binding capacity, serum electrophoresis, and serum ceruplasmin.
For elevated alkaline phosphatase, “First thing I do … is to do a GGT [gamma glutamyl transferase],” Dr. Tambunan said. “If the GGT comes back elevated, it suggests that the majority of the alkaline [phosphatase] is elevated due to the liver,” and an ultrasound should be performed to look for gallstones or an obstruction and in women a antimitochondrial antibody test should be ordered to check for primary biliary cirrhosis.
If the initial lab work points to bone, then order parathyroid, THS, and PSA tests and a bone scan looking for Paget's disease in women and prostate cancer in men.
For elevated bilirubin levels, obtain direct and indirect bilirubin levels. If indirect is slightly elevated, suspect Gilbert disease, or if markedly elevated liver disease. If direct is elevated, treat (cholestasis) or if very elevated suspect a biliary obstruction.