Elevated ALT, AST, and GGT: Differential Diagnosis

Tue, 17 Jan 2023 11:27:44 +0300

A 36-year-old woman contacted an online medical assistance service for help interpreting her test results. She categorically denies alcohol consumption. Complaints include: poor sleep, yellow coating on the tongue, chest pain and pain in the right side, increased heart rate at night (HR up to 150 bpm). Medication history: folic acid, Omega-3 unsaturated fatty acids, vitamin D, Niperten (Bisoprolol beta1-selective adrenergic blocker). Cipralex, amitriptyline (antidepressants). Elevated gamma-GT, aminotransferases, vitamin B12, and decreased red blood cell count. ❓What are the causes of these deviations? ✅Interpretation: First, it is necessary to calculate the de Ritis index (AST/ALT): 36/58 = 0.62. According to the scientific article: Rej, Robert. (1989). Aminotransferases in Disease. Clinics in Laboratory Medicine. 9. 667-687. Such a decrease in the de Ritis ratio may indicate viral hepatitis or extrahepatic biliary obstruction. It is necessary to ask the patient about a history of transfusions and to order additional tests for HBs antigen (Australian antigen, hepatitis B) and antibodies to hepatitis C (total) from venous blood. According to a new publication by Vetrova L. et al. Health ecology: factors of spread and consequences of viral hepatitis manifestation //BIO Web of Conferences. – EDP Sciences, 2021. for our patient’s age, the mean ± standard deviation for ALT in viral hepatitis can be: 76.1±9.10, but the possible range of values is: 18-195 U/L (despite the common belief that in viral hepatitis, ALT sharply increases 10-fold compared to the upper reference interval). Given the categorical denial of alcohol consumption, an ALT level lower than the average in the viral hepatitis patient population, and normal bilirubin, with elevated gamma-GT, the most likely diagnosis is still extrahepatic biliary obstruction. But look at the alkaline phosphatase level. It is also normal! This is a very sensitive marker of cholestatic pathology. What remains is non-alcoholic steatohepatitis (NASH), as it is the most common cause of elevated transaminases. Also, drug-induced hepatitis is quite possible, considering the list of medications being taken. It is also very important to rule out thyroid disease (check serum TSH level). In thyroiditis, aminotransferase elevation occurs in 33% of cases according to the publication: Saha, B., & Maity, C. (2002). Alteration of Serum Enzymes in Primary Hypothyroidism. Clinical Chemistry and Laboratory Medicine, 40(6). How would you continue the interpretation? What other tests would you recommend for our patient?

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Elevated ALT, AST, and GGT: Differential Diagnosis