Transaminitis (elevated liver enzymes) is a common, often incidental, finding in paediatric practice, frequently found when investigating non-hepatic complaints. Alanine aminotransferase (ALT) is one such enzyme. It predominantly resides in hepatocytes and plays a major role in amino acid metabolism and gluconeogenesis. Hepatocellular injury leads to release of ALT, increasing its serum concentration, making it a marker of liver damage. Investigations of liver problems can be complex.

A quality improvement audit project was devised to study the assessment, management, and outcomes of transaminitis (raised ALT) in a busy paediatric unit in a large district general hospital to inform the production of a standardised and streamlined transaminitis guideline.

We retrospectively audited children (1–16 years) with elevated serum ALT identified between June 2019 and June 2021. Exclusion criteria were transaminitis on neonatal prolonged jaundice screening, children who passed away and those with unavailable records. Data were collected using a special audit tool and analysed using Microsoft Excel and SPSS.

Total 99 children met the inclusion criteria; most were ≥11y (53.1%) followed by 6–10y (20.4%). Children were categorised into one of 10 presentation groups with nearly 2/5 being ‘acute non-febrile illness with no clinical evidence of liver disease’ followed by 1/4 being ‘acute febrile illness with no clinical evidence of liver disease’. Only 3 children had an acute presentation with clinical evidence of liver disease. Mean initial ALT was 255 (mode = 57, range = 50–5896) and mean peak ALT was 397 (mode = 57, range = 50–11900). Around 80% of initial and 70% of peak ALTs were <200. Only 2/5 of children had any aetiological investigations on initial presentation. In 64% of presentations an aetiological diagnosis was not reached; the most common diagnoses were Epstein-Barr Viral infection, fatty liver disease and secondary to medication use, respectively. About 60% of patients with elevated ALT had normal levels on repeat testing within 1 month, with only 13% persisting beyond 6 months.

In conclusion, most transaminitis was mild (<200), with greater ALTs corresponding with clinical evidence of liver disease being present. Approach to investigation and management was variable, with differing aetiological investigations performed at different points following initial recognition. It was common to not reach a diagnosis for elevated ALT and to not follow-up until complete resolution. It was noted that 7 children were diagnosed as fatty liver disease on BMI and USS findings without the full panel of aetiological investigations recommended by the British Society of Paediatric Gastroenterology, Hepatology and Nutrition.¹ This work has highlighted a variable approach to this common presenting issue. We would recommend working towards a standardised approach or guideline both to ensure important underlying clinical conditions are not missed but also children are not exposed to unnecessary investigation.

Reference

1. UK Fatty Liver Guideline. British Society of Paediatric Gastroenterology, Hepatology and Nutrition, 2020. (Accessed December 1st, 2022, at https://bspghan.org.uk/wp-content/uploads/2020/08/LSG_UK-Fatty-Liver-Guideline-August-2020.pdf)