Resident Report 3/2 – Transaminitis

Teaching Points:

  • LFT abnormalities may manifest itself in a cholestatic or hepatocellular pattern
    • Cholestatic pattern
      • elevation of bilirubin, high alk phos in relation to AS and ALT elevation
    • Hepatocellular pattern
      • Elevation of AST and ALT in relation to alk phos and bilirubin levels
  • Pattern can determine initial imaging work-up
    • Clear cholestatic pattern
      • May proceed to EUS, MRCP or ERCP since these studies would be indicated despite getting abdominal ultrasound
    • Clear hepatocellular pattern
      • May proceed to CT initially
    • If picture is mixed:
      • Can start off with abdominal ultrasound
  • Differentials of cholestatic LFTs in IBD patients
    • Primary sclerosing cholangitis – occurs in about 10-15% of IBD patients (more associated with ulcerative colitis)
    • Primary biliary cirrhosis – associated with anti-mitochondrial antibody
      • Seen in middle aged female with chronic onset, manifesting with pruritis and gradual jaundice
    • Viral hepatitis
    • Autoimmune hepatitis
    • Post-obstructive etiologies including pancreatic CA, cholangio, gallstone, etc.
    • Alcoholic hepatitis
  • Patients on 6-MP or azathioprine for their IBD need to have their enzymatic TPMT levels checked.
    • Metabolites of 6-MP can cause cytopenia and also hepatotoxicity.

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