Isolated alteration of liver enzyme particularly in an apparently healthy child can be a diagnostic challenge for the clinician. In this review the Authors provide a guide to alteration of liver enzyme activity based on four main clinical-biochemical syndromes. “Acute pure cytolytic syndrome” reflects acute hepatocellular damage as can be observed in infectious, autoimmune toxic or ischemic hepatitis or in case of acute severe muscular damage. Some acute hepatocellular damage can be cryptogenic in origin. “Acute mixed cytolytic syndrome” reflects acute biliary and hepatocellular damage as observed in acute biliary obstruction of normal or damaged bile tree, viral infections with cholangiotropic viruses, vasculitic damage of the biliary tree as observed in Kawasaki disease and drug induced liver injury with cholestatic features. “Chronic pure cytolytic syndrome” can reflect either chronic muscle or liver damage of different etiology and is generally asymptomatic. Inborn error of metabolism may account for a large number of cases. Isolated increase in aspartate aminotransferase suggests macrotransaminasemia. “Chronic mixed cytolytic syndrome” can be observed in case of persistent bile duct damage of various causes.
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