From the Guidelines
These liver enzyme elevations (AST 190, ALT 228) indicate moderate hepatocellular injury that requires prompt evaluation, and I recommend a comprehensive workup to determine the underlying cause. The AST:ALT ratio is less than 1, which typically points toward non-alcoholic causes such as viral hepatitis, medication effect, or non-alcoholic fatty liver disease rather than alcoholic liver disease 1.
Initial Steps
- Discontinue any potentially hepatotoxic medications
- Avoid alcohol completely
- Schedule follow-up liver function tests within 1-2 weeks
Comprehensive Workup
- Hepatitis serologies (A, B, C) to rule out viral hepatitis 1
- Autoimmune markers (ANA, anti-smooth muscle antibody) to evaluate for autoimmune hepatitis 1
- Iron studies and ceruloplasmin level to assess for hereditary hemochromatosis or Wilson disease 1
- Abdominal ultrasound to evaluate for structural liver abnormalities, such as fatty liver disease or cirrhosis 1
Additional Considerations
- Maintain good hydration and a healthy diet low in processed foods while waiting for test results
- Consider additional tests, such as serum creatine kinase or hepatitis E testing, if initial results are inconclusive or if there are symptoms suggestive of other conditions 1
- The degree of elevation (3-5x normal) warrants investigation but is not immediately life-threatening in the absence of symptoms or coagulopathy 1
From the Research
Interpretation of Liver Transaminase Levels
The provided liver transaminase levels are AST 190 and ALT 228. According to the study 2, approximately 10% to 20% of the general population has elevated liver chemistry levels, including aspartate and alanine transaminases.
Possible Causes of Elevated Transaminase Levels
The causes of mildly elevated transaminase levels (two to five times the upper limit of normal) can be categorized into:
- Metabolic dysfunction-associated steatotic liver disease (MASLD) and alcoholic liver disease as the most common causes 2
- Uncommon causes such as drug-induced liver injury, chronic hepatitis B and C, and hereditary hemochromatosis 2
- Rare causes including alpha1-antitrypsin deficiency, autoimmune hepatitis, and Wilson disease 2
- Extrahepatic causes like celiac disease, hyperthyroidism, rhabdomyolysis, and pregnancy-associated liver disease 2
Evaluation and Testing
Initial laboratory testing should assess complete blood cell count with platelets, blood glucose, lipid profile, hepatitis B surface antigen, hepatitis C antibody, serum albumin, iron, total iron-binding capacity, and ferritin 2. If MASLD is suspected, the FIB-4 Index Score or NAFLD Fibrosis Score can be used to predict which patients are at risk for fibrosis and may benefit from further testing or referral to a hepatologist 2.
Classification of Abnormal Liver Biochemical Tests
Abnormal liver biochemical tests can be categorized based on the pattern and the magnitude of aminotransferases elevation, including hepatocellular pattern or cholestatic pattern, and can be further sub-classified based on the magnitude of aminotransferase elevation to mild, moderate, and severe 3.
Clinical Guideline for Evaluation of Abnormal Liver Chemistries
The evaluation of hepatocellular injury includes testing for viral hepatitis A, B, and C, assessment for nonalcoholic fatty liver disease and alcoholic liver disease, screening for hereditary hemochromatosis, autoimmune hepatitis, Wilson's disease, and alpha-1 antitrypsin deficiency 4. A liver biopsy may be considered when serologic testing and imaging fails to elucidate a diagnosis, to stage a condition, or when multiple diagnoses are possible 4.