Hay et al.
(1) recently reported on "The nature of unexplained chronic aminotransferase elevations of a mild to moderate degree in asymptomatic patients." This article improves our understanding of this group of patients, who are commonly referred to gastroenterologists for evaluation. The finding of autoimmune markers in steatohepatitis is an important insight.
Two points deserve clarification: (i) In the introduction, it is stated that persistent aminotransferase abnormalities in asymptomatic patients with chronic hepatitis B infection typically have been associated with mild histologic disease. There are experiences that contradict this statement. In a study of Baltimore volunteer blood donors, seven of 17 patients with chronic hepatitis B infection and abnormal aminotransferases had chronic active hepatitis, three with cirrhosis (2). Seven of nine blood donors in Amsterdam with abnormal aminotransferases had chronic active hepatitis, five with cirrhosis or "cirrhosis beginning" (3).
(ii) It would be interesting and important to know the percentage of patients with chronic active hepatitis or steatohepatitis lacking clinical manifestations and with only aminotransferase abnormalities. This information would help in clinical decision making in relation to selection of patients for liver biopsy. Although the patients in this article are asymptomatic, 55% had clinical manifestations of liver disease (skin findings, liver and/ or spleen enlargement and esophageal varices) and 60% had three abnormal conventional liver tests. The high frequency of significant chronic liver disease found in this population would not be expected in a group of patients lacking clinical manifestations and having only isolated aminotransferase abnormalities.