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Practice Rational Testing

Investigating mildly abnormal serum aminotransferase values

BMJ 2010; 341 doi: (Published 30 July 2010) Cite this as: BMJ 2010;341:c4039
  1. Jeremy F L Cobbold, clinical lecturer,
  2. Quentin M Anstee, clinical lecturer ,
  3. Howard C Thomas, professor of medicine
  1. 1Hepatology and Gastroenterology Section, Division of Diabetes, Endocrinology and Metabolism, Department of Medicine, Imperial College London, London W2 1NY
  1. Correspondence to: Q M Anstee q.anstee{at}

    How do you approach the investigation of a patient with mildly abnormal aminotransferase tests? This article will guide you through diagnosis and assessment of severity

    A 43 year old man of South Asian origin, working as a software engineer, was found to have a serum alanine aminotransferase value of 64 (normal range 0-40) U/l at a routine health check arranged by his company. He had an unremarkable medical history and took no regular medications. Of note, his father had died of ischaemic heart disease at the age of 67 years. Clinical examination was unremarkable. His height was 1.7 m and weight 79 kg (body mass index 27). The results of the remaining basic liver blood tests were normal (bilirubin 12 (0-20) μmol/l; alkaline phosphatase 105 (30-150) U/l; albumin 38 (35-50) g/l). Full blood count and serum urea, creatinine, and electrolytes were also within normal limits.

    What is the next investigation?

    An initial history and clinical examination are necessary for determining the likely aetiology of the raised alanine aminotransferase value, the presence of any comorbidity that may accelerate disease progression, and the presence of stigmata of chronic liver disease. History should include details of alcohol intake, risk factors for chronic viral hepatitis, use of prescription medication, and over the counter or herbal remedies.

    Liver biochemistry

    The general practitioner requested a repeat serum alanine aminotransferase value (which was 58 U/l) and serum aspartate aminotransferase and γ glutamyltransferase values (52 (0-40) U/l and 55 (11-51) U/l respectively).

    Raised serum alanine aminotransferase values usually indicate hepatocellular damage. Aminotransferase values of less than five times the upper limit of normal are often considered mild, while those more than five times the upper limit of normal are severe, representing more extensive hepatocellular injury. Mildly raised values do not exclude severe chronic liver disease; indeed evidence exists that substantial liver damage may be present …

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