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Severe Transaminitis

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Transaminitis refers to an increase in circulating levels of transaminases (ie, AST and ALT) classically indicative of liver injury. Hepatobiliary disease spans a wide breadth of various pathologies and should consider a patient’s physical exam, clinical context, imaging, other labs (GGT, bilirubin, alkaline phosphatase, etc); however, having AST and ALT levels in the thousands (yes, that’s bad) usually narrows the differential considerably.

  • Ischemic liver: “shock” from systemic hypoperfusion, obstruction (ie, Budd-Chiari, etc.)
  • Acute viral hepatitis (hepatitis A or B, acute hepatitis C, HSV)
  • Drug-induced: Tylenol toxicity by far!
  • Autoimmune hepatitis exacerbation

Although these are the common diagnoses, management and therapeutic options vary considerably based on the acuity, comorbidities, etiology, and institution’s capabilities. Furthermore, transaminitis in the thousands doesn’t exclude other diagnoses like biliary obstruction, Wilson’s disease, etc.

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