Elevated Liver Enzymes in Northern Virginia

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Elevated liver enzymes are one of the most common surprises on routine bloodwork, and they are a frequent reason a primary care physician refers someone to a gastroenterologist. Most people feel completely fine when the result comes back. That can make it hard to know how seriously to take a number flagged "high" on a lab report. This guide explains what the liver tests on a standard blood panel measure, what different patterns and levels of elevation can point to, the common causes of elevated liver enzymes, and how a gastroenterologist works out which one applies to you.

This article is general education, not medical advice. What your results mean depends on your history, your other test results, and how the numbers change over time, so talk with your physicians about your own situation.

What elevated liver enzymes means

When people say "liver enzymes," they usually mean a group of tests included in a comprehensive metabolic panel, the standard blood panel ordered at many checkups. The American College of Gastroenterology (ACG) addresses these tests in its clinical guideline on the evaluation of abnormal liver chemistries (Kwo and colleagues, 2017), which remains the ACG's current guideline on the topic. The guideline makes a point that is useful for patients: these tests are markers of liver injury, not measures of how well the liver is working. For that reason, the ACG says they should be called liver chemistries or liver tests, not "liver function tests."

In plain terms, elevated liver enzymes tell you that something may be irritating or injuring liver cells or slowing the flow of bile. They do not, on their own, tell you what that something is or how much it matters. Finding that out is the purpose of the evaluation.

The tests behind elevated liver enzymes

• ALT (alanine aminotransferase). The ACG notes that ALT is found mainly in the liver, which makes it a more specific marker of liver cell injury.
• AST (aspartate aminotransferase). AST is found in the liver but also in heart muscle, skeletal muscle, kidney, and brain. The ACG notes that a high AST without a high ALT suggests a heart or muscle source rather than the liver.
• Alkaline phosphatase. Found in the liver and also in bone, placenta, intestine, and kidney. Bone is the most common source outside the liver.
• Bilirubin. A yellow pigment the liver processes and clears into bile. When it builds up, it can cause jaundice, a yellowing of the skin and eyes.

Albumin and the prothrombin time (a clotting test) are sometimes listed alongside these. The ACG describes them as markers of how well the liver is making proteins, though they can be affected by conditions outside the liver too.

What is a normal ALT level

This is where many people are caught off guard. Every lab sets its own reference range, usually built so that about 95 percent of a reference population falls inside it. The ACG guideline notes that by that definition, 2.5 percent of the population will be above the upper limit of normal even if they are healthy.

The guideline also argues that many lab ranges for ALT are set too high. Based on studies of people without risk factors for liver disease, the ACG states that a true healthy normal ALT is about 29 to 33 IU/L for men and 19 to 25 IU/L for women, and that levels above this should be assessed by a physician. It adds two other points worth knowing:

• ALT rises with body mass index, so weight is part of the picture.
• A normal ALT does not always rule out significant liver disease.

The practical takeaway: an ALT of 40 may sit inside your lab's printed range and still be above the level the ACG considers healthy, especially for a woman. If your results were described as "slightly high" or "borderline," it is reasonable to ask how they compare with the ACG's numbers.

Patterns of elevated liver enzymes

Gastroenterologists look less at any single number and more at which tests are elevated relative to each other. The ACG guideline describes four patterns:

• Hepatocellular pattern. ALT and AST are high out of proportion to alkaline phosphatase. This points toward injury to the liver cells themselves, as in fatty liver disease, viral hepatitis, or medication effects.
• Cholestatic pattern. Alkaline phosphatase is high out of proportion to ALT and AST. This points toward a problem with bile flow, either a blockage in the bile ducts or a condition inside the liver that slows bile.
• Mixed pattern. Both are elevated.
• Isolated high bilirubin. Bilirubin is up while ALT, AST, and alkaline phosphatase are normal.

To sort hepatocellular from cholestatic injury more precisely, physicians sometimes calculate what the ACG calls the R ratio, which compares how far ALT and alkaline phosphatase each sit above their upper limits. A ratio above 5 suggests hepatocellular injury, below 2 suggests cholestatic injury, and 2 to 5 is mixed.

How high are your elevated liver enzymes

The size of the elevation also guides the next step. The ACG defines ALT and AST elevations by how many times above the upper limit of normal (ULN) they are:

• Borderline: less than 2 times the ULN
• Mild: 2 to 5 times the ULN
• Moderate: 5 to 15 times the ULN
• Severe: more than 15 times the ULN
• Massive: above 10,000 IU/L

Most elevated liver enzymes found on routine bloodwork fall in the borderline or mild range, and most are evaluated through a scheduled visit. The ACG states that moderate, severe, and massive elevations require immediate evaluation.

Common causes of elevated liver enzymes

The list of possible causes is long, but a handful account for most cases. The ACG guideline describes these as the core of the evaluation for a hepatocellular pattern.

Fatty liver disease

Fatty liver disease is now called MASLD, short for metabolic dysfunction-associated steatotic liver disease, and was previously known as NAFLD. The ACG guideline notes that it is associated with obesity, diabetes, high cholesterol and triglycerides, and high blood pressure, and should be strongly considered in people with mild ALT and AST elevations. It typically raises ALT more than AST, and levels rarely go above 300 IU/L. Our guide to fatty liver disease and hepatitis covers who is at risk and how it is managed.

Alcohol

Alcohol-related liver injury has a pattern of its own. The ACG notes that about 90 percent of people with alcohol-related liver disease have an AST higher than their ALT, and more than 70 percent have an AST at least twice their ALT. The guideline cites significant alcohol use as more than 210 grams a week for men and more than 140 grams a week for women, roughly 15 and 10 standard U.S. drinks. Alcohol and fatty liver disease often overlap in the same person. Our page on alcohol-associated liver disease covers the stages, testing, and what improves when drinking stops.

Viral hepatitis

Hepatitis B and hepatitis C can both cause long-term liver inflammation for years without symptoms, which is why testing for them is a standard part of evaluating elevated liver enzymes. Our guide to chronic hepatitis B and C explains who should be tested and why testing matters in a region as internationally connected as Northern Virginia, where many residents were born in parts of the world where hepatitis B is common.

Medications and supplements

Prescription drugs, over-the-counter medicines, and herbal or dietary supplements can all raise liver enzymes. The ACG says a careful history of everything a person takes is essential, including products that are not prescribed. Among supplements, the guideline names green tea extract, ephedra, chaparral, germander, ji bu huan, and shark cartilage as associated with liver injury. In people with very high ALT levels, above 1,000 IU/L, the ACG stresses an accurate history of acetaminophen use, including combination cold and pain products that contain it. The National Institutes of Health maintains LiverTox, a reference on drugs and supplements linked to liver injury.

Please do not stop a prescribed medication on your own because of a liver test result. Your physician can weigh whether a medicine is the likely cause and whether there is a suitable alternative.

Less common liver causes

When the common causes are ruled out, the ACG guideline lists further conditions to check, including hereditary hemochromatosis (iron overload), autoimmune hepatitis, Wilson's disease (a rare copper disorder), and alpha-1 antitrypsin deficiency. Autoimmune hepatitis is more common in women than men, and the ACG notes it can occur alongside other autoimmune conditions such as thyroid disease and ulcerative colitis.

Causes outside the liver

Not every case of elevated liver enzymes starts in the liver. The ACG lists celiac disease, thyroid disease (both underactive and overactive), heart failure, and muscle disorders among the causes found outside the liver. It also notes that strenuous exercise or muscle injury can raise AST, sometimes along with ALT. If you had a hard workout, a fall, or a muscle injury in the days before your blood draw, mention it.

Elevated alkaline phosphatase and bilirubin

When alkaline phosphatase is the main number that is high, the first question is whether it is coming from the liver or from bone. The ACG notes that a GGT (gamma-glutamyl transferase) test can help: an elevated GGT suggests the alkaline phosphatase is coming from the liver. Alkaline phosphatase also rises naturally with bone turnover in children, and the ACG notes it rises in older adults, especially women over 50.

Once the liver is confirmed as the source, the ACG recommends a right upper quadrant ultrasound. Widened bile ducts suggest a blockage, which can be caused by gallstones that have moved into the bile duct or, less often, by a narrowing or a tumor. When a blockage needs to be examined or cleared, a procedure called ERCP may be involved. If the ultrasound is normal, the ACG recommends looking for causes inside the liver, including primary biliary cholangitis (PBC), primary sclerosing cholangitis (PSC), and drug-induced liver injury. The ACG notes that PSC is commonly associated with inflammatory bowel disease of the colon. Our guide to autoimmune liver disease covers PBC, PSC, and autoimmune hepatitis in more detail.

A high bilirubin with otherwise normal tests

The ACG advises that an elevated bilirubin be split into its two forms, direct (conjugated) and indirect (unconjugated). A high direct bilirubin generally points to liver disease or a bile duct blockage.

A mildly high indirect bilirubin with otherwise normal liver tests is very often Gilbert's syndrome. The ACG describes it as the most common cause of elevated unconjugated bilirubin, affecting 3 to 7 percent of the U.S. population. It is an inherited difference in how the liver processes bilirubin. The level usually stays below 3 mg/dL, can rise with fasting or illness, and once the diagnosis is made, the ACG notes that further evaluation is not routinely needed.

How elevated liver enzymes are evaluated

The first step is often simply repeating the test. The ACG guideline advises repeating the lab panel, or adding a clarifying test such as GGT, to confirm that the result is truly abnormal before starting a full workup. A single mild elevation sometimes returns to normal on its own.

From there, the evaluation usually includes:

• A detailed history. Alcohol use, every medication and supplement, past liver or gallbladder problems, travel, family history of liver disease, and conditions such as diabetes, obesity, thyroid disease, and celiac disease.
• A physical exam to look for signs of long-term liver disease.
• Blood tests chosen by the pattern and level of elevation. For borderline and mild elevations, the ACG describes stopping medicines that may harm the liver and stopping alcohol, along with testing for hemochromatosis, fatty liver disease, and viral hepatitis, then autoimmune liver disease, Wilson's disease, and alpha-1 antitrypsin deficiency if those are normal. For moderate elevations of 5 to 15 times the ULN, the ACG describes testing for hepatitis A, B, and C, an iron panel, copper studies, alpha-1 antitrypsin, and autoimmune markers.
• Imaging. An ultrasound can show fat in the liver, signs of scarring, gallstones, or widened bile ducts.

When a liver biopsy is considered

Most people with elevated liver enzymes never need a biopsy. The ACG says a liver biopsy may be considered when blood tests and imaging do not reveal a diagnosis, when it is important to stage how much scarring is present, or when more than one diagnosis is possible.

Why elevated liver enzymes deserve follow-up

It can be tempting to set aside a mildly abnormal result when you feel well. The ACG guideline notes that multiple studies have linked an elevated ALT to a higher risk of dying from liver disease, even in people without known risk factors. Many liver conditions, including fatty liver disease, chronic hepatitis B and C, and early cirrhosis, cause no symptoms for years. Our guide to silent digestive conditions explains why a blood test is often the only early clue. Most causes of elevated liver enzymes are manageable, and many are reversible, which is exactly why finding them early is worth the effort.

Symptoms that need prompt attention

Most elevated liver enzymes are found in people who feel fine. Some symptoms, though, call for faster care: yellowing of the skin or eyes, dark urine, pale stools, confusion or unusual drowsiness, vomiting blood, a swollen abdomen, or severe pain in the upper right abdomen, especially with fever. If you have any of these, or if a physician has told you your liver enzymes are very high, seek same-day care or go to an emergency department rather than waiting for a routine appointment. Our guide to when to see a gastroenterologist explains how to tell a scheduled concern from an urgent one.

The ACG clinical guideline on abnormal liver chemistries is available to read in full for those who want the clinical detail.

Evaluation for elevated liver enzymes in Northern Virginia with GC of NoVA

Gastroenterology Center of Northern Virginia sees patients across Arlington, Annandale, and the surrounding communities who have been referred for elevated liver enzymes, most often by a primary care physician after routine bloodwork. Our physicians can review your results and how they have changed over time, sort out the pattern, order the blood tests and imaging that fit your situation, and work with your other physicians on next steps, whether the cause turns out to be fatty liver disease, viral hepatitis, a medication, or something less common. We see patients at our Arlington office, next to VHC Health, and our Annandale office, in the Woodburn Medical complex.

If this is your first visit, our guide to your first gastroenterologist visit explains what to bring. For a liver evaluation, that includes copies of your past bloodwork, so trends can be compared, and a complete list of your medications and supplements, including anything over the counter. To schedule, contact our Arlington office at (703) 522-7476 or our Annandale office at (703) 560-6106, or learn more at gcofnova.com.

This article is for general education and is not medical advice. Talk with a qualified gastroenterologist about your symptoms, diagnosis, and treatment options.