CASE 55
A 48-year-old man presented to an internist for a physical exam, since he had not been to a physician for many years. He was asymptomatic, but routine chemistry panel showed elevated transaminases.
LABORATORY STUDIES
Diagnostic Work-Up
Table 55-1 lists the likely causes of an elevation of liver enzymes (differential diagnosis). For suspected infection, serology is the mainstay of specific diagnosis. The hepatitis panel should include testing of viral antigen and antibodies.
TABLE 55-1 Differential Diagnosis and Rationale for Inclusion (consideration)
Rationale: Elevations in hepatic transaminases can be due to many causes. Hepatitis is a relatively common clinical syndrome associated with hepatocyte injury, jaundice, and elevation of liver enzymes (ALT and AST >500 IU/L). It may be asymptomatic. The major infectious causes of hepatitis are hepatitis viruses (HAV, HBV, or HCV), where elevation of ALT is more pronounced than AST. Alcoholic liver injury does not lead to ALT or AST levels >500 IU/L and AST is higher than ALT. Sometimes risk factors can shed light on one etiology over others. Many drugs can also cause asymptomatic elevations in transaminases. Gallstone hepatitis may cause similar symptoms due to blockage of bile but may not show marked increase in liver enzymes. Infection with CMV and EBV can be associated with elevated liver enzymes but without significant jaundice.
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