From the Guidelines
If you have elevated AST, ALT, and GGT liver enzymes, you should schedule an appointment with your healthcare provider for a comprehensive evaluation, as recommended by the most recent guidelines 1. The evaluation should include a detailed history, inventory of medications, and a physical examination to assess the patient’s risk factors for liver disease, medications, alcohol consumption, comorbid conditions, and signs and symptoms of hepatic disease 1.
Key Considerations
- The pattern and degree of elevation can provide clues about the underlying cause, such as AST/ALT ratio suggesting alcoholic versus non-alcoholic liver disease, while elevated GGT often indicates biliary tract issues or alcohol use 1.
- The severity of abnormal aminotransferase can be classified as mild, moderate, or severe, with moderate and severe elevations requiring prompt medical attention 1.
- Referral to gastroenterology should be considered for persistently elevated or worsening transaminases, as recommended by recent guidelines 1.
Next Steps
- Avoid alcohol completely and stop taking any non-essential medications or supplements while waiting for the appointment.
- Follow a healthy diet low in processed foods and sugar, and consider gradual weight loss through healthy eating and regular exercise if overweight.
- The healthcare provider will likely order additional tests, including a complete liver panel, hepatitis screening, and possibly an ultrasound or other imaging of the liver, to determine the underlying cause of the elevated enzymes 1.
From the Research
Elevated AST, ALT, and GGT: Next Steps
Elevated levels of aspartate aminotransferase (AST), alanine aminotransferase (ALT), and gamma-glutamyl transferase (GGT) can indicate liver damage or disease. The following steps can be taken to evaluate and manage elevated liver enzymes:
- Evaluate the degree of elevation of AST and ALT to guide the evaluation, as the degree of elevation can help determine the underlying cause of liver damage 2
- Test for viral hepatitis A, B, and C, as well as assess for nonalcoholic fatty liver disease and alcoholic liver disease 2
- Screen for hereditary hemochromatosis, autoimmune hepatitis, Wilson's disease, and alpha-1 antitrypsin deficiency 2
- Consider a liver biopsy if serologic testing and imaging fail to elucidate a diagnosis, or if multiple diagnoses are possible 2
Association with Obesity
Obesity has been associated with elevated levels of liver enzymes, including ALT and GGT 3. However, this association may be influenced by dietary intake, and further studies are needed to determine the independent effects of obesity on liver function 3.
Interpretation of AST/ALT Ratio
The ratio of AST to ALT can be used to help determine the underlying cause of liver damage. A ratio of greater than 2.0 is often seen in alcoholic liver disease, while a ratio of less than 1.0 is often seen in chronic hepatitis and chronic cholestatic syndromes 4. However, this ratio may be less helpful in the presence of cirrhosis, as the ratio may rise to greater than 1.0 when cirrhosis is present 4.
Evaluation of Alkaline Phosphatase Elevation
If an alkaline phosphatase elevation is determined to be of hepatic origin, testing for primary biliary cholangitis and primary sclerosing cholangitis should be undertaken 2. Total bilirubin elevation can occur in either cholestatic or hepatocellular diseases, and elevated total serum bilirubin levels should be fractionated to direct and indirect bilirubin fractions 2.