Abnormal Liver Function Tests: Elevations in ALT and AST, Which Predominate Over Elevations of Alkaline Phosphatase (ALP), 5'-NT, and/or Gamma Glutamyltransferase (GGT)

Differential Diagnosis

If the diseases in the list below increase in severity, there may be findings suggestive of cirrhosis with or without hepatic failure:

  • Viral hepatitis, multiple forms (see chapters on Viral Hepatitis A, B, and C)

  • Hemochromatosis

  • Wilson disease

  • Alpha-1-antitrypsin deficiency

  • Hepatocellular carcinoma

Suggested Additional Lab Testing

Total bilirubin and unconjugated bilirubin are markedly elevated in hepatic failure.

  • Prothrombin time is elevated as a result of decreased synthesis of coagulation factors.

  • Aminotransferase levels may increase and then decrease rapidly when there is significant and permanent loss of hepatocytes.

  • Serum creatinine may be elevated as evidence of hepatorenal syndrome.

  • Low blood glucose, elevated white blood cell (WBC) count, low platelet count, and low serum albumin are also common in hepatic failure.

  • Serum ceruloplasmin is low (90% of the serum copper is complexed to this protein).

  • Twenty-four-hour urinary copper excretion is elevated.

  • Liver function tests may be normal, but, as the disease progresses, abnormal values appear.

  • Serum copper is usually elevated but may be normal or low.

  • Hepatic copper concentration is markedly elevated because of the low amount of serum ceruloplasmin; an elevated hepatic copper concentration is highly indicative of Wilson disease.

Alpha-1-antitrypsin deficiency

  • Serum alpha-1-antitrypsin level is low.

  • Abnormal liver function tests are detectable in adults who suffer liver damage, but they may be normal in early stages of disease.

  • Liver biopsy can show characteristic red cytoplasmic granules demonstrable by a PAS stain of the liver. Hepatocellular carcinoma requires histopathologic examination of a liver biopsy for diagnosis.

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