Rutgers Medical School of Robert Wood Johnson - Saint Peter's University Hospital New Brunswick, New Jersey
Introduction: Clinicians are required to assess abnormal liver chemistries on a daily basis. The ACG provides clear specific recommendations in management of patients admitted for elevated liver enzymes (LEs). We here aimed to evaluate to the current hospital practice in evaluation of elevated LEs and to highlight how we may further incorporate the appropriate guidance to provide evidence-based care.
Methods: We retrospectively identified 50 patients consecutively admitted for elevated LEs between 1/2021 and 1/2022 (utilizing ICD code R74.01). We focused our analysis on patients with moderate (5-15X ULN) and severe ( >15X ULN) elevation in LEs since inpatient workup is highly recommended in these patients. The current ACG guidelines recommend the following tests in these patients: HAV IgM, HAV IgG, HBsAg, HBcAb IgM, HBcAb IgG, HBsAb, HCV Ab with PCR confirmation if positive, HSV, EBV, CMV, ceruloplasmin, iron panel, ANA, ASMA, Anti-LKM, IgG, serum drug and urine toxicology panels, and doppler abdominal ultrasound.
Results: In the 50 patients admitted for elevated LEs, 30 patients were men, and the majority were White (35 patients). The mean age of the cohort was 50±11 years. The mean and SD of liver tests were: ALT 338±336 U/L, AST 329±330 U/L, ALP 253±254 U/L, bilirubin 5.2±8.7 mg/dL, and INR 1.2±1.3. Overall, a complete workup for the elevated liver enzymes was performed in 12/50 patients only (24%) (Figure 1A). Among the 33 patients who had “moderate” or “severe” elevations of LEs, the average number of tests and imaging studies ordered for each patient was 7/24 only (29%). Furthermore, complete evaluation, based on the ACG recommendation, was not performed at admission in any of the patients. After initial workup, a defined diagnosis was documented in 19/33 patients (58%). Gastroenterology (GI) consultation was requested in 21/33 patients (2/3rds). In 16/21 (76%) patients where GI was consulted, the diagnosis was established only after GI recommended further investigations based on the ACG guidelines. Length of stay was 2.6±2.7 days.
Discussion: Our data suggest that in most of the patients the proper workup has been incomplete or delayed which may have prolonged the length of hospital stay and cost of care. Thus, we recommended education of the medical team on the existing guidelines (including consulting gastroenterology specialist) as well as incorporation of the recommendations in a proper order set to improve clinician efficiency and provide decision-making guidance (Figure 1B).
