From the Guidelines
Isolated elevated liver enzymes can be caused by various factors, and a thorough clinical evaluation is necessary to determine the underlying cause. When evaluating abnormal liver chemistry tests, it is essential to consider the clinical context of the patient, including their medical history, medication use, and risk factors for liver disease 1. The initial evaluation of abnormal liver tests should include a detailed history, inventory of medications, and a physical examination to assess for signs and symptoms of hepatic disease 1. According to the guidelines on the management of abnormal liver blood tests, a thorough clinical history, including age, ethnicity, symptoms, comorbidity, drug history, and family history, should be obtained to explore possible causes of liver dysfunction 1. Investigations should include a standard liver aetiology screen or core panel to identify the cause of damage and exclude additional pathologies 1. It is crucial to determine the cause of isolated elevated liver enzymes, as some causes, such as viral hepatitis or autoimmune hepatitis, may require immediate referral to a specialist clinic for further evaluation and treatment 1. In patients with abnormal liver blood tests, it is not recommended to simply repeat the same panel of tests but to determine the cause unless there is a high index of clinical suspicion that it is a transient finding 1. A comprehensive evaluation, including a thorough clinical history, physical examination, and laboratory tests, is necessary to determine the exact cause of isolated elevated liver enzymes and to guide further management. The choice of blood tests in the core panel is influenced by prevalence and the identification of treatable causes of liver disease, and patients with evidence of specific liver diseases, such as hepatitis B or C, autoimmune hepatitis, or primary biliary cholangitis, should be referred to a specialist clinic in accordance with locally agreed guidance 1.
From the FDA Drug Label
Abnormalities in liver enzymes have not been associated with Ursodiol therapy and, in fact, Ursodiol has been shown to decrease liver enzyme levels in liver disease. The answer is no, isolated elevated liver enzymes are not likely to be caused by ursodeoxycholic acid (PO) therapy, as the drug has been shown to decrease liver enzyme levels in liver disease 2.
From the Research
Isolated Elevated Liver Enzymes
Isolated elevated liver enzymes can be caused by various factors, including:
- Hepatocellular integrity disturbance, which can be found in patients with viral hepatitis, genetic liver diseases, or drug-induced liver diseases 3
- Alcoholic or non-alcoholic fatty liver disease, and infiltrating liver diseases, characterized by a predominant rise in γ-glutamyl transpeptidase 3
- Extrahepatic diseases, which can cause similarly increased serum activities, such as obstruction of the large bile ducts by gall stones or tumors 3
Evaluation and Management
The evaluation and management of isolated elevated liver enzymes should be guided by both the clinical presentation and the pattern of injury 4.
- A step-wise algorithm can be used to interpret abnormal elevation of liver enzymes in asymptomatic patients, classifying enzyme alterations on the basis of pattern (hepatocellular, cholestatic, and isolated hyperbilirubinemia) 5
- An algorithmic approach can be taken to help narrow the spectrum of a differential diagnosis, by separating disease processes into groupings of hepatocellular, cholestatic, or functioning liver, based on underlying enzymatic roles 6
Testing Strategies
The choice of testing strategy for patients with elevated liver enzymes depends on various factors, including the pre-test probabilities and prior evaluations performed:
- Extensive testing strategy may be more cost-effective when there are no clues available at the time of evaluation, but it can generate more false positives 7
- Focused testing strategy becomes the most cost-effective strategy when accounting for pre-test probabilities and prior evaluations performed, and it can save time, money, and prevent false positives 7