What is the significance of mildly elevated liver enzymes, including Alanine Transaminase (ALT) of 139, Alkaline Phosphatase (ALP) of 87, and Aspartate Transaminase (AST) of 106, in a 24-year-old female with incidental hepatic steatosis (fatty liver disease) on abdominal ultrasound, negative Hepatitis screen, normal Bilirubin, and normal International Normalized Ratio (INR)?

From the Guidelines

This patient with mildly elevated liver enzymes and incidental hepatic steatosis should be managed with lifestyle modifications, including weight loss, increased physical activity, and dietary changes, as the primary approach to reduce the risk of progression to advanced liver disease, as recommended by the most recent guidelines 1. The patient's elevated liver enzymes, including Alanine Transaminase (ALT) of 139, Alkaline Phosphatase (ALP) of 87, and Aspartate Transaminase (AST) of 106, in the context of hepatic steatosis on abdominal ultrasound, suggest non-alcoholic fatty liver disease (NAFLD) as the likely diagnosis.

• The normal bilirubin and International Normalized Ratio (INR) levels indicate preserved liver function without evidence of advanced liver disease.
• The absence of other liver diseases, as indicated by a negative hepatitis screen, further supports the diagnosis of NAFLD.
• According to the guidelines, all individuals with steatosis should be screened for features of metabolic syndrome, independent of liver enzymes 1.
• The patient should aim for a weight loss of 7-10% through a combination of caloric restriction and increased physical activity, with at least 150 minutes of moderate-intensity exercise weekly, and reduce daily caloric intake by 500-1000 calories 1.
• Specific dietary changes should include limiting processed foods, refined carbohydrates, and sugary beverages, while increasing consumption of vegetables, fruits, lean proteins, and healthy fats.
• Alcohol should be avoided completely, and consideration should be given to discontinuing medications that may worsen steatosis.
• Follow-up should include repeat liver enzymes in 3 months to assess response to lifestyle changes, with consideration of referral to hepatology if enzymes remain significantly elevated despite adherence to recommendations.
• The use of noninvasive tests, such as elastography or fibrosis biomarkers, may be considered to assess the risk of fibrosis, but referral to a liver specialist and liver biopsy may be required for definitive diagnosis 1.

From the Research

Significance of Mildly Elevated Liver Enzymes

The patient's liver enzyme levels, including Alanine Transaminase (ALT) of 139, Alkaline Phosphatase (ALP) of 87, and Aspartate Transaminase (AST) of 106, are mildly elevated. In the context of incidental hepatic steatosis (fatty liver disease) on abdominal ultrasound, negative Hepatitis screen, normal Bilirubin, and normal International Normalized Ratio (INR), these enzyme levels may indicate nonalcoholic fatty liver disease (NAFLD) 2.

Nonalcoholic Fatty Liver Disease (NAFLD)

NAFLD is the most common form of liver disease in the United States, affecting up to 30% of adults 2. The disease is characterized by hepatic steatosis, which is the accumulation of excess fat in liver cells. NAFLD can progress to nonalcoholic steatohepatitis (NASH), a more severe form of the disease that can lead to fibrosis, cirrhosis, and even liver cancer.

Association with Insulin Resistance and Metabolic Syndrome

Hepatic steatosis is strongly associated with insulin resistance, glucose intolerance, and type 2 diabetes mellitus 3. The disease is also linked to hypertriglyceridemia, low levels of HDL, and metabolic syndrome. The patient's mildly elevated liver enzymes may be a marker of underlying insulin resistance and metabolic dysfunction.

Role of Exercise and Physical Activity

Exercise and physical activity have been shown to improve liver fat and reduce the risk of NAFLD, independent of dietary modification 4, 5. A systematic review and meta-analysis found that exercise alone can reduce liver fat by -2.4% (mean, 95% CI) without dietary intervention 4. Another study found that physical activity was inversely associated with NAFLD in a dose-dependent manner, independent of visceral obesity and insulin resistance 5.

Ultrasound Examination and Liver Echogenicity

The patient's abdominal ultrasound showed incidental hepatic steatosis, which is consistent with NAFLD. Increased liver echogenicity at ultrasound examination reflects the degree of steatosis but not fibrosis in asymptomatic patients with mild/moderate abnormalities of liver transaminases 6. The study found that liver echogenicity was normal in 5 out of 9 patients with septal fibrosis and in 4 out of 6 patients with cirrhosis, suggesting that ultrasound examination is not reliable for diagnosing fibrosis or cirrhosis.

Key Findings

• Mildly elevated liver enzymes may indicate NAFLD in the context of incidental hepatic steatosis on abdominal ultrasound 2.
• NAFLD is associated with insulin resistance, glucose intolerance, and type 2 diabetes mellitus 3.
• Exercise and physical activity can improve liver fat and reduce the risk of NAFLD, independent of dietary modification 4, 5.
• Ultrasound examination can detect hepatic steatosis but is not reliable for diagnosing fibrosis or cirrhosis 6.