What is the significance of elevated liver function tests, including hyperbilirubinemia, mildly elevated AST, elevated ALT, and elevated Alkaline Phosphatase in a 50-year-old female?

From the Guidelines

The patient's lab results indicate a resolving hepatocellular injury, and I recommend continued monitoring of liver enzymes in 4-6 weeks to ensure complete normalization, as suggested by the guidelines on the management of abnormal liver blood tests 1. The most recent labs from three days ago show improvement with ALT (51 unit/L) now within normal range, AST (27 unit/L) normalized, but alkaline phosphatase remains slightly elevated at 95 unit/L. Seven days ago, there were significant elevations in ALT (121 unit/L), AST (77 unit/L), and total bilirubin (1.3 mg/dL), suggesting acute liver inflammation. In the meantime, it is essential to avoid alcohol, acetaminophen, and review all medications and supplements with your doctor as they may be contributing to liver stress, as recommended by the american gastroenterological association medical position statement: evaluation of liver chemistry tests 1. Some key points to consider in the management of abnormal liver blood tests include:

• Initial investigation for potential liver disease should include bilirubin, albumin, alanine aminotransferase (ALT), alkaline phosphatase (ALP) and γ-glutamyltransferase (GGT), together with a full blood count if not already performed within the previous 12 months, as stated in the guidelines on the management of abnormal liver blood tests 1.
• Abnormal liver blood test results should only be interpreted after review of the previous results, past medical history and current medical condition, as recommended by the guidelines on the management of abnormal liver blood tests 1.
• The extent of liver blood test abnormality is not necessarily a guide to clinical significance, which is determined by the specific analyte that is abnormal and the clinical context, as stated in the guidelines on the management of abnormal liver blood tests 1.
• Patients with abnormal liver blood tests should be considered for investigation with a liver aetiology screen irrespective of level and duration of abnormality, as recommended by the guidelines on the management of abnormal liver blood tests 1. It is also crucial to stay well-hydrated and maintain a healthy diet low in processed foods. If symptoms like fatigue, abdominal pain, dark urine, or yellowing of skin/eyes develop, seek immediate medical attention. The improving trend is reassuring, but identifying the underlying cause of the initial elevation is important to prevent recurrence, as common causes include viral hepatitis, medication effects, alcohol use, fatty liver disease, or autoimmune conditions, as discussed in the guidelines on the management of abnormal liver blood tests 1.

From the Research

Laboratory Results

The provided laboratory results show elevations in certain liver enzymes, including:

• ALT (SGPT): 51 units/L (elevated) [current], 121 units/L (elevated) [7 days ago], 16 units/L [1 year ago], and 13 units/L [2 years ago]
• AST (SGOT): 27 units/L [current], 77 units/L (elevated) [7 days ago], 22 units/L [1 year ago], and 20 units/L [2 years ago]
• Alkaline Phosphatase: 95 units/L (elevated) [current], 85 units/L [7 days ago], 63 units/L [1 year ago], and 74 units/L [2 years ago]
• Total Bilirubin: 0.5 mg/dL [current], 1.3 mg/dL (elevated) [7 days ago], 1.0 mg/dL [1 year ago], and 1.0 mg/dL [2 years ago]

Evaluation of Elevated Liver Enzymes

According to 2, the evaluation of hepatocellular injury, such as elevated ALT and AST levels, includes testing for viral hepatitis, nonalcoholic fatty liver disease, and alcoholic liver disease. The degree of elevation of ALT and AST helps guide the evaluation. In this case, the patient's ALT and AST levels are elevated, suggesting hepatocellular injury.

Patterns of Injury

2 also states that hepatocellular injury is defined as disproportionate elevation of AST and ALT levels compared with alkaline phosphatase levels. In this patient's case, the alkaline phosphatase level is also elevated, which may indicate a mixed pattern of injury.

Diagnostic Work-up

3 suggests that the evaluation of elevated liver enzymes should be guided by both the clinical presentation and the pattern of injury. 4 recommends that patients with predominantly aminotransferase elevations, such as this patient, should be evaluated for acute or chronic hepatitis from various causes. Imaging evaluation and liver biopsy may be considered if less invasive investigations are unfruitful.

Next Steps

Based on the provided laboratory results and the studies cited, the next steps in the evaluation of this patient's elevated liver enzymes may include:

• Further testing for viral hepatitis, nonalcoholic fatty liver disease, and alcoholic liver disease
• Imaging evaluation to exclude large bile duct disorders and infiltrative/mass lesions
• Consideration of a liver biopsy if less invasive investigations are unfruitful
• Assessment for other potential causes of elevated liver enzymes, such as medication adverse effects or hereditary hemochromatosis, as suggested by 2 and 4.