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The abnormality chosen is:
an elevated ALANINE AMINOTRANSFERASE (ALT/SGPT) level greater than 40 U/L. Elevation of this enzyme is more specific to hepatocellular damage than AST. The degree of elevation does not correlate with the degree of underlying liver injury, and levels may even be normal in cases of advanced cirrhosis or slightly elevated without any evidence of liver injury. ALT is sensitive, such that the ingestion of two aspirins can raise the level as much as 15% above normal for a day. ALT may be significantly elevated (approximately three to four times) in patients receiving heparin therapy. This abnormality is generally reversible with discontinuation of heparin therapy.
Elevations in excess of 1,000 U/L are indicative of acute viral hepatitis (A and B), toxin/medication exposure/overdose (always consider acetaminophen as a possible etiology), and shock (hypoperfusion) liver. Elevations below 400 U/L are usually seen with other liver disorders to include: chronic viral hepatitis, hemochromatosis, alcoholic liver disease, fatty liver, nonalcoholic steatohepatitis, autoimmune hepatitis, Wilson's disease, alpha-1 antitrypsin deficiency, celiac disease, and certain medications (NSAIDs, aspirin, antibiotics, statins, methotrexate, antiseizure medications and antituberculous medications). When there is associated biliary colic symptoms or pancreatitis, then choledocholithiasis may be the cause. Transaminasemia occurs rapidly with obstruction of the common bile duct whereas the expected rise in alkaline phosphatase may take longer to manifest; therefore, in the acute setting of choledocholithiasis, the patient may manifest biliary pain with transaminasemia and a normal alkaline phosphatase. Asymptomatic mild elevations of the ALT (less than twice the normal value) without an obvious underlying cause should not prompt an aggressive work-up other than checking viral hepatitis serologies for chronic hepatitis B or C infection, as often times an etiology is not discovered even after liver biopsy. This being said, obesity has become a major problem for many medical patients, and may result in fatty liver disease, as well as being a risk factor for progression towards cirrhosis; therefore, obese patients with mild and persistent ALT elevations should be advised about proper diet and exercise habits to target a normal BMI and then retesting to see if transaminases normalize.
