We will try to remember the differential for elevated transaminases by going through the work-up for elevated transaminases
- Assess liver damage and liver function
- Repeat AST, ALT, ALP, GGT, bilirubin
- Get INR, aPTT
- Get CBC including platelets
- Ultrasound of liver if initial blood work comes back unknown for etiology
- Most common cause of elevated transaminases in a child is going to be viral etiology
- Hepatitis A IgG (and the similar Hepatitis E)
- Remember the main difference between Hep A and E is that there is no vaccine for Hep E, but both hep A and E infection leads to lifelong immunity and they are both transmitted through the fecal-oral route
- Hepatitis B serology
- HBsAg (hepatitis B surface antigen, seen in acute infection)
- anti-HepB surface antigen (looking for whether patient is susceptible or immune to Hep B infection)
- Ebstein Barr serology (looking for mononucleoosis)
- IgM and IgG EBV viral capsid antigen has high sensitivity and specificity for acute mono. Antibodies persist for life
- In mono you can also see lymphocytosis with a lot atypical lymphocytes, splenomegaly, elevated LFTs and mild thrombocytopenia
- HHV-6 IgM (looking for Roseola)
- Parvovirus serology
- Parvovirus IgM – within 10 days of exposure and lasts for 2-3 months – acutely infectious
- Parvovirus IgG – appears after first 2 weeks of infection
- CMV (also known as HHV-5) serology
- CMV IgM and IgG
- Hepatitis A IgG (and the similar Hepatitis E)
- If viral workup is negative, then time to do workup for metabolic disease, autoimmune hepatitis
- Autoimmune hepatitis: total IgG and IgA, auto-antibodies
- Wilson disease: Ceruloplasmin (low), serum copper, 24h-urinary copper, Kaiser-Fleischer ring in the eyes on examination
- Alpha-1 antitrypsin deficiency: anti-trypsin level
- Cystic fibrosis: sweat test
- Pancreatic insufficiency: fecal elastase
- Fatty liver disease: triglycerides