AN EPIDEMIOLOGICAL SURVEY : 103 PATIENTS WITH ELEVATED TRANSAMINASES IN A RANDOM CHECK

I.Staikos, K.Krapis, N.Aggelis, K.Karamitsos

GENERAL HOSPITAL OF LARISSA, INTERNAL MEDICINE DEPARTMENT

The elevated transaminases (AST/ALT) is a common laboratory finding and its clinical impact often concerns the doctor of the primary, secondary even tertiary medical care.

Their elevation implies liver cell damage and is followed by necrosis.

ALT seems to be the most sensitive enzyme of liver damage, as it is most found in liver, whereas AST is found in muscles, heart, kidneys, lungs, pancreas, red blood and white blood cells, brain.

At about 5% of the general population have elevated values of transaminases ALT/AST without any symptomatology.

Cuadrado A, Crespo J. Hypertransaminasemia in patients with negative viral markers. Rev Esp Enferm Dig 2004; 96: 484-500. table 1

Common causes of elevated transaminases

Alcohol abuse

Hepatitis B (chronic)

Hepatitis C (chronic)

Steatosis/steatohepatitis

Medications/toxins/dietary supplements

Less common causes

Autoimmune hepatitis

Hyperthyroidism

Exercise

Hemochromatosis (primary or secondary)

Alpha1-antitrypsin deficiency

Wilson’s disease

Rare causes

Celiac disease

Addison's Disease

Myopathy

Macro-AST

Γ.Ν.Νταλέκος, Χ.Λιάσκος, Κ.Ζάχου, Ε.Μακρή και Μ.Βενιζέλος. Αντιμετώπιση ασυμπτωματικών ασθενών με διαταραχές των ηπατικών ενζύμων, ΚΕΕΛ

For epidemiological reasons there has been a record of patients who have developed elevated values of transaminases in random check at the outpatient clinic of the Internal Medicine Department. Patients who were referred to the outpatient clinic from smaller public health services and private doctors’ offices for the probe of this finding were also included in this sample.

Patients’ sample

Patients who were included in the survey belonged to both sexes and to the whole range of ages.

As inclusion criteria have been used the presence of elevated values of transaminases (AST and/or ALT>40) in at least two measurements in time between 7-14 days.

The exclusion criteria are a) the presence of diagnosed liver disease, b) the presence of known systematic disease with possible liver contribution, c) clinical symptomatology which has to do with liver and biliary disease.

All the patients included come from the wide area of Thessaly, although there were not used criteria for exclusion concerning the origin or the domicile.

The final sample is composed by 103 patients in total, from whom 53 were male and 50 female.

Their age range is between 22 and 76 years old.

67 patients were receiving a sort of medication.

34 patients presented another disorder of the liver biochemistry except for transaninases, mostly GGT.

92 patients had elevated values <5 times more than the normal, while 11 patients had values five or more times elevated than the ones which are considered to be normal.

28

39

36Age Range

20-4040-6060-80

disease/age 20-40 40-60 60-80 total %

HBV 13 6 3 22 21

HCV 9 3 4 16 15

Alcoholic 3 6 9 18 17

Drug induced 0 4 7 11 10

NAFLD 2 4 3 9 9

CMV 0 1 0 1 1

Gallstones 0 1 0 1 1

Wilson 10 0 1 1

Autoimmune hepatitis

0 2 0 2 2

No diagnosis 6 11 5 24 23

From the results, a not predictable raise of the percentages of viral hepatitis has been occurred (38 cases- 37%), mainly concerning the young and middle ages. Furthermore, there was a slight ascendance of HBV over HCV (21% over 15%).

From the patients with viral hepatitis (HBV and HBC) 55% had AST/ALT ratio > 0,8, whereas in 45% it was < 0,8.

In addition, a great impact was developed by the alcoholic disease (17%), where the main part of the patients was middle and over aged, with a clear distribution of those who were over 60 years old. These patients developed AST/ALT ratio > 2 in the percentage of 78%.

The drug induced hepatitis followed with 10%. Specifically, seven cases were attributed to statins, three to NSAIDs and one to fibrates.The NAFLD, whose percentages, in general acknowledgement, are constantly rising, was found surprisingly low in this specific sample with a percentage of only 9% (nine cases). From those, six were suffering from Diabetes Melitus and two were obese. In this particular group the AST/ALT ratio was < 1 in seven out of the nine cases (77%)

The no diagnosis/other group consists of cases where laboratory finding was no long present in later examinations and it resolved by itself.

Two cases of autoimmune hepatitis and one of Wilson's disease are worth being mentioned.

The recorded raise of viral hepatitis, probably a result of the financial crisis and the decline of the subsistence level, sounds the alarm for the doctor, as an early diagnosis can lead to an effective treatment, whereas the delay of the intervention can be disastrous for the patient, even for public health.

Moreover, it is clear that the alcoholic disease of liver is a great concern for health care. From the 18 patients with alcoholic liver disease, three of them had clues of early cirrhosis and only one end stage liver disease, showing that the early enough intervention can have spectacular results.

Finally, three cases needed hospitalisation and probe in the Hepatology Department of Univerity of Thessaly, fact that shows the importance of the particular structure.

REFERENCES

1. Cuadrado A, Crespo J. Hypertransaminasemia in patients with negative viral markers. Rev Esp Enferm Dig 2004; 96: 484-500.

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6. Γ.Ν.Νταλέκος, Χ.Λιάσκος, Κ.Ζάχου, Ε.Μακρή και Μ.Βενιζέλος. Αντιμετώπιση ασυμπτωματικών ασθενών με διαταραχές των ηπατικών ενζύμων, ΚΕΕΛ