ACG Clinical Guideline: Evaluation of Abnormal Liver Chemistries Interview with:

Paul Y. Kwo, MD, FACG Stanford University School of Medicine

Dr. Paul Y. Kwo

Paul Y. Kwo, MD, FACG
Stanford University School of Medicine What is the background for this study?

Response: This guideline, which was jointly authored by Drs. Kwo, Cohen, and Lim provides a framework for physicians to approach the very common problem encountered of a patient whose liver chemistries are abnormal. This is particularly relevant as there remain large pools of individuals who have yet to be diagnosed with chronic hepatitis B and C, non-alcoholic fatty liver disease, advanced liver disease as well as less common conditions, all of whom will require evaluation.

In particular, the rise in the prevalence of non-alcoholic fatty liver disease worldwide will be addressed in part by identifying and evaluating these individuals prior to the development of advanced fibrosis. The guideline takes clinicians through a step-wise approach to the evaluation of elevated aminotransferase (ALT and AST), alkaline phosphatase, and bilirubin levels including appropriate historical questions, important physical examination findings, laboratory , radiological evaluation and finally liver biopsy if required. What are the main findings?

Response: What is unique about the ACG Guideline is that for the first time in a liver test guideline, a normal healthy ALT level is defined for women and men (19-25 IU/L W, 29-33 IU/L M), and levels above this should be assessed by physicians. This decision was based on the emerging data over the past decade demonstrating that ALT levels above our defined thresholds are associated with higher liver related mortality rates across a broad range of populations world-wide including populations from the US, Europe, and Asia that is driven in part by the obesity epidemic. With the broad range of upper limit of normal levels for ALT levels that vary from institution to institution, clinicians may not think to evaluate an ALT level of 70 IU/L as this may be within the normal level for the reporting laboratory even though this level of elevation is associated with increased liver related mortality. What should readers take away from your report?

Response: To help clinicians proceed with evaluation of elevated aminotransferase levels, we have devised algorithms that allow a graded approach to those with elevated aminotransferase elevations by categorizing these elevations as minimal, mild, moderate and severe, as well as giving specific guidelines as to when immediate evaluation is required and when a more limited evaluation can be performed with subsequent evaluation if liver chemistries fail to normalize. We recognize that it will take time for clinicians to recognize the newer lower limits of ALT levels that should now be considered normal. Algorithms to evaluate abnormalities in alkaline phosphatase and bilirubin levels are also included in the new ACG guideline provides algorithms to help clinicians efficiently evaluate these abnormalities including suggested serologic and radiologic evaluations as well as when liver biopsy should be considered. Thank you for your contribution to the community.


ACG Clinical Guideline: Evaluation of Abnormal Liver Chemistries
Paul Y Kwo, Stanley M Cohen and Joseph K Lim
The American Journal of Gastroenterology 112, 18-35 (January 2017) | doi:10.1038/ajg.2016.517
Note: Content is Not intended as medical advice. Please consult your health care provider regarding your specific medical condition and questions.

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Last Updated on January 5, 2017 by Marie Benz MD FAAD