Hepatocellular necrosis:

1.†† Elevated AST(SGOT), ALT(SGPT).

2.†† Bilis may be elevated, PT may be prolonged, albumin may be decreased.

3.†† ALT more specific for liver than AST

4.†† AST-to-ALT ratio

a.†† >2: alcohol induced hepatic injury

b.†† <1: acute or chronic viral hepatitis

1.†† DDx: alcoholic hepatitis, HAV, HBV, HCV, alpha1-antitrypsin deficiency, autoimmune hepatitis, hemochromatosis, Wilsonís, nonalcoholic steatohepatitis, ischemic hepatitis

2.†† Additonal tests: ANA, serum ceruloplasmin, Fe/TIBC, hep serologies, SPEP



1.†† Marked elevation in AP (Typically 4-fold)

2.†† May be elevation of bilis, PT (responsive to Vit K), mild elevation in transaminases.

3.†† AP non-specific (bone, placenta, intestine, kidney, leukocytes).May be elevated by EtOH, pancreatic dz, MI, uremia, COPD, RA, DM, drugs).Needs to be confirmed by heated AP (BONE BURNS) GGTP, LAP, or 5í-NT.

4.†† DDx: PBC (AMA+), autoimmune cholangiopathy (AMA-), PSC, extrahepatic obstruction.

5.†† Additional tests: abd US


Infiltrative process:

1.†† Elevated AP

2.†† May be mild elevation of transaminases and bilis.

3.†† DDx: granulomatous process, ca




1.†† Exclude pregnancy, physiologic causes

2.†† Check cholestatic markers (GGTP, 5íNT, LAP)

a.†† normal: consider bone dz (Pagetís, hyperPT, bone mets), ectopic AP.

b.††††††††††† ekevated

i.††††††††† <3-fold: consider hepatocellular injury

ii.††††††††† >3-fold: abd US or CT

A.††††† dilated ducts: choledocholithilasis, pancreatic ca, cholangioca, biliary stricture, pancreatitis

B.††††† non-dilated ducts

1.††††††††††† focal hepatic defects: primary or metastatic ca of liver, pyogenic/amebic process

2.††††††††††† normal or diffusely abnormal liver: liver bx or ERCP


Transaminitis >1000: acute viral hep, drug/toxin induced, ischemia

Transaminitis <500-1000: EtOH, extrahepatic obstruction, drug induced.

Direct hyperbilirubinemia: >50% conjugated (direct)

Indirect hyperbilirubinemia: >80% unconjugated (indirect)



Moseley RH, Medical Clinics of North America,80(5), Sept 1996