ACG clinical guideline: evaluation of abnormal liver chemistries

Kwo, Paul Y; Cohen, Stanley M; Lim, Joseph K

doi:10.1038/ajg.2016.517

Cited by 1,222Liver Disease Diagnosis and TreatmentLiver Diseases and ImmunityDrug-Induced Hepatotoxicity and Protection

ACG clinical guideline: evaluation of abnormal liver chemistries

Kwo, Paul Y, Cohen, Stanley M, Lim, Joseph K·2017·American Journal of Gastroenterology

DOI 10.1038/ajg.2016.517

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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.

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Authors: Kwo, P. Y., Cohen, S. M., & Lim, J. K.
Affiliations: Stanford Medicine (US)
University Hospitals of Cleveland (US)
Yale University (US)
Corresponding author: Kwo, Paul Y
ORCID: Kwo, Paul Y
Lim, Joseph K
Venue: American Journal of Gastroenterology
Publisher: Ovid Technologies (Wolters Kluwer Health)
Published: 2017-01
Volume: 112
Issue: 1
Pages: 18-35
ISSN: 0002-9270 (ISSN-L)
DOI: 10.1038/ajg.2016.517
OpenAlex: W2563118732
Cited by: 1,222
References: 98
Citations by year: 2026: 161 · 2025: 159 · 2024: 176 · 2023: 158 · 2022: 144 · 2021: 141 · 2020: 116 · 2019: 81 · 2018: 62 · 2017: 18 · 2016: 1 · 2014: 1 · 2012: 1
FWCI: 50.65
Type: journal article
Language: en
Open access: closed
Licence: www.springer.com/tdm (unspecified)
Locations: The American Journal of Gastroenterology (publishedVersion)
PubMed (publishedVersion)
Topics: Health Sciences › Medicine › Epidemiology › Liver Disease Diagnosis and Treatment
Health Sciences › Medicine › Hepatology › Liver Diseases and Immunity
Life Sciences › Pharmacology, Toxicology and Pharmaceutics › Pharmacology › Drug-Induced Hepatotoxicity and Protection
Keywords: alanine aminotransferase, aspartate aminotransferase, alkaline phosphatase, bilirubin, hepatocyte injury, cholestatic liver injury, viral hepatitis screening, non-alcoholic fatty liver disease, alcoholic liver disease, hereditary hemochromatosis, autoimmune hepatitis, Wilson's disease, alpha-1 antitrypsin deficiency, primary biliary cirrhosis, primary sclerosing cholangitis, liver biopsy, liver-related mortality
MeSH terms: Alanine Transaminase, Alkaline Phosphatase, Aspartate Aminotransferases, Bilirubin, Biopsy, Cholestasis, Hemochromatosis, Hepatitis, Viral, Human, Hepatolenticular Degeneration, Humans, Liver, Liver Diseases, Liver Diseases, Alcoholic, Hepatitis, Autoimmune, alpha 1-Antitrypsin Deficiency, Chemical and Drug Induced Liver Injury, Non-alcoholic Fatty Liver Disease

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ACG clinical guideline: evaluation of abnormal liver chemistries

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