From the Guidelines
Elevated liver enzymes, particularly a pattern where SGOT (AST) and SGPT (ALT) are slightly raised while ALP (alkaline phosphatase) is significantly elevated, typically suggests cholestatic liver disease, as indicated by the most recent study 1. This pattern often occurs in conditions that obstruct bile flow, such as:
- Primary biliary cholangitis
- Primary sclerosing cholangitis
- Drug-induced cholestasis
- Biliary obstruction from gallstones, tumors, or strictures Patients with this enzyme pattern should undergo further evaluation, including:
- Ultrasound or other imaging of the biliary system to rule out obstruction
- Additional blood tests like gamma-glutamyl transferase (GGT), bilirubin levels, and autoimmune markers If medication-induced cholestasis is suspected, discontinuing the offending drug (commonly antibiotics, antiepileptics, or hormonal therapies) may be necessary, as suggested by 1. Treatment depends on the underlying cause, with ursodeoxycholic acid at 13-15 mg/kg/day often used for primary biliary cholangitis, while obstructive causes may require endoscopic or surgical intervention, as noted in 1 and 1. This enzyme pattern reflects impaired bile excretion, with the disproportionate ALP elevation occurring because this enzyme is concentrated in the bile duct epithelium and is induced during cholestatic conditions, while hepatocellular damage (reflected by AST/ALT) is less prominent. Key considerations in managing these patients include:
- Identifying and addressing the underlying cause of cholestasis
- Monitoring liver function tests and adjusting treatment as needed
- Considering the potential for complications such as cirrhosis or liver failure, as discussed in 1.
From the Research
Conditions with Slightly Raised SGOT and SGPT, and Significantly Raised ALP
- The conditions in which SGOT (AST) and SGPT (ALT) are slightly raised, and ALP is significantly raised, can be associated with cholestatic liver disease, as indicated by the significant elevation of ALP levels compared to AST and ALT levels 2.
- Primary biliary cholangitis (PBC) is a condition where ALP levels are significantly raised, and AST and ALT levels are slightly raised. In PBC patients treated with ursodeoxycholic acid (UDCA), normal ALP levels are associated with better long-term outcomes 3.
- Cholestasis, which is the disruption of bile flow, can lead to liver fibrosis and significantly raised ALP levels. Combination therapy with UDCA and glutathione has been shown to improve liver function in cholestasis-induced rats, with significant decreases in ALP levels 4.
- The evaluation of abnormal liver chemistries, including significantly raised ALP levels, should include testing for primary biliary cholangitis and primary sclerosing cholangitis, as well as other conditions such as viral hepatitis, nonalcoholic fatty liver disease, and autoimmune hepatitis 2.
- In some cases, slightly raised AST and ALT levels, along with significantly raised ALP levels, may be associated with chronic hepatitis, as seen in a study where UDCA treatment improved AST and ALT levels, but not ALP levels 5.