Persistent hypertransaminasemia in asymptomatic children: a stepwise approach

Abstract

We aimed to examine the major causes of isolated chronic hypertransaminasemia in asymptomatic children and develop a comprehensive diagnostic flow diagram. A MEDLINE search inclusive of publications throughout August 2012 was performed. We found only a small number of publications that had comprehensively investigated this topic. Consequently, it was difficult to construct a diagnostic flowchart similar to those already available for adults. In children, a "retesting panel" prescription, including gamma-glutamyl transpeptidase and creatine kinase in addition to aminotransferases, is considered a reasonable approach for proficiently confirming the persistence of the abnormality, ruling out cholestatic hepatopathies and myopathies, and guiding the subsequent diagnostic steps. If re-evaluation of physical and historical findings suggests specific etiologies, then these should be evaluated in the initial enzyme retesting panel. A simple multi-step diagnostic algorithm incorporating a large number of possible pediatric scenarios, in addition to the few common to adults, is available. Accurately classifying a child with asymptomatic persistent hypertransaminasemia may be a difficult task, but the results are critical for preventing the progression of an underlying, possibly occult, condition later in childhood or during transition. Given the high benefit/cost ratio of preventing hepatic deterioration, no effort should be spared in diagnosing and properly treating each case of persistent hypertransaminasemia in pediatric patients.

Keywords: Aminotransferase; Children; Hypertransaminasemia; Liver disease; Transaminase.

Figure 1

Diagnostic algorithm for the diagnosis of pediatric mild chronic asymptomatic hypertransaminasemia. Modified from the reference of 28. ALT: Alanine aminotransferase; AST: Aspartate aminotransferase; CB: Conjugated bilirubin; UB: Unconjugated bilirubin; CPK: Creatine kinase; GGT: Gamma-glutamyl transferase; PE: Pulmonary embolism; PEG: Polyethylene glycol; PT: Prothrombin time; PTT: Partial thromboplastin time; US: Ultrasound; MRI: Magnetic resonance imaging; ERCP: Endoscopic retrograde cholangiopancreatography; pANCA: Perinuclear anti-neutrophil cytoplasmic antibodies; HBV: Hepatitis B virus; HCV: Hepatitis C virus; AIH: Autoimmune hepatitis; α1 ATD: α1-antitrypsin deficiency.