Elevated Liver Enzymes
Mild
ALT < 5x ULN
Hepatocellular
ALT or AST > ALP
Cholestatic (does not always 
cause jaundice) ALP > AST or ALT
NAFLD 10% 
population
ERCP for dx and 
therapy
ETOH hepatitis 
usually cholestatic, 
and usually ALT < 
300
DX ALF if 
↑INR and hepatic 
encephalopathy
• Viral
• Drugs/Toxins
• Ischemia
• Autoimmune
• Wilson’s
• Pregnancy
• AFLP
• HELLP
US - Dilated Bile 
Ducts
US – Normal Bile 
Ducts 
Severe
ALT > 15x ULN
Moderate
ALT 5 - 15x ULN
• Viral
• Drugs
• AIH
• Wilson’s
• Hemochromatosis
• NAFLD
• Others
• NAFLD
• Alcohol
• Viral
• Hemochromatosis
• Drugs
• AIH
• A1AT deficiency
• Wilson’s
• Others
• Cholestatic disease
• PBC
• PSC
• Alcoholic hepatitis
• Drugs
• TPN
• Sepsis
• Infiltrative
• Sarcoid
• Amyloid
• Malignancy
• Infection
• Cirrhosis (any)
• Congenital
• Biliary Atresia
• Alagille Syndrome
• Progressive Familial 
Intracholestasis
• Common Bile Duct 
Stone
• Biliary stricture
• PSC
• Worms/flukes
• Cholangiocarcinoma
• Pancreatic cancer
• Others
Dx by biopsy 
± MRI/MRCP