Utility of Hepatic Transaminases in Children With Concern for Abuse

by Joelle N. Simpson

One of the fears of working in the Emergency Department is missing a diagnosis that could mean significant morbidity or mortality for your patient.  As such, I chose the following article from this month’s Pediatrics titled:  Utility of Hepatic Transaminases in Children With Concern for Abuse

The premise of the article was an attempt to establish a threshold for using transaminases as a screen for patients with concern for abdominal trauma secondary to abuse.

This study is part of the ExSTRA  (Examining Siblings To Recognize Abuse) research network which is a multicenter, observational, cross-sectional network of 20 child abuse teams that endorsed a common screening protocol for the siblings and household contacts of children younger than 10 years old evaluated for potential physical abuse. (Dr Katherine Deye from CAPC is our CNMC ExSTRA investigator)

This study was a retrospective secondary analysis where the investigators determined rates of identified abdominal injuries and results of transaminase, amylase, and lipase testing.

They determined a transaminase threshold of 80 IU/L yielded sensitivity of 83.8% and specificity of 83.1% as a screen to detect occult intraabdominal injury in children evaluated for physical abuse. (Note: Abdominal injuries were confirmed by CT). Among children with an initial AST or ALT 80, the posttest probability for intraabdominal injury was 20.0% in this study.

The authors state agree that although classic signs and symptoms of intraabdominal injury, such as abdominal tenderness, bruising, or distention, can increase concerns for abdominal injury, none of these findings is sufficiently sensitive.

Final thoughts from the authors: Intraabdominal injuries are uncommon among children evaluated for physical abuse, but they carry significant mortality. Hepatic transaminases can increase sensitivity for occult intraabdominal injury relative to the clinical examination alone in children with concern for physical abuse. Children with elevated transaminases (AST or ALT>80 IU/L) should undergo definitive testingfor abdominal injury, such as CT scan.