What is the significance of elevated Alkaline Phosphatase (Alk Phosphate) at 142, Aspartate Aminotransferase (AST) at 42, and Alanine Aminotransferase (ALT) at 94?

From the Guidelines

These lab values indicate liver function abnormalities that require medical evaluation, as your alkaline phosphatase (142), AST (42), and ALT (94) are all elevated above normal ranges, suggesting liver inflammation or injury. The pattern with ALT higher than AST and elevated alkaline phosphatase could indicate various liver conditions such as viral hepatitis, medication-induced liver injury, fatty liver disease, or biliary obstruction, as noted in the American College of Radiology's appropriateness criteria for abnormal liver function tests 1. You should schedule an appointment with your healthcare provider promptly for further assessment, as recommended by the American Gastroenterological Association's medical position statement on the evaluation of liver chemistry tests 1. They will likely order additional tests such as hepatitis serologies, ultrasound imaging of the liver, and a complete metabolic panel. In the meantime, avoid alcohol consumption and review all medications (including over-the-counter drugs and supplements) with your doctor as some may contribute to liver inflammation, as suggested by the guidelines for evaluating serum liver chemistries 1. Do not stop any prescribed medications without medical guidance. These elevations are significant enough to warrant attention but don't typically represent an immediate emergency unless accompanied by symptoms like severe abdominal pain, yellowing of the skin/eyes, or confusion.

Some key points to consider:

• The severity of abnormal aminotransferase can be classified as mild, moderate, or severe, with moderate and severe being discussed collectively due to significant clinical overlap 1.
• Pathologically increased levels of ALP may occur in cholestatic liver disease, which can show elevated ALP with or without elevated bilirubin 1.
• The interpretation of all abnormal liver chemistries must be taken in the clinical context of a given patient, including a detailed history, inventory of medications, and a physical examination 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. However, patients given Ursodiol should have SGOT (AST) and SGPT (ALT) measured at the initiation of therapy and thereafter as indicated by the particular clinical circumstances

The patient's liver enzyme levels are:

• Alk phosphate: 142
• AST: 42
• ALT: 94 These values do not directly indicate a problem with ursodiol therapy, as the drug label states that ursodiol has not been associated with liver damage and may even decrease liver enzyme levels in liver disease 2. However, it is recommended to monitor SGOT (AST) and SGPT (ALT) levels during therapy. Given the information provided, no conclusion can be drawn about the potential impact of ursodiol on the patient's liver enzyme levels without further context or comparison to baseline values.

From the Research

Interpretation of Liver Enzyme Results

The provided liver enzyme results are:

• Alk phosphate: 142
• AST: 42
• ALT: 94

Patterns of Liver Enzyme Elevation

According to 3, there are three patterns of increased liver enzymes:

• A predominant increase in transaminase activities (AST and ALT) reflects a disturbance of hepatocellular integrity, which can be found in patients with viral hepatitis, genetic liver diseases, or drug-induced liver diseases.
• A pattern characterized by high serum alkaline phosphatase and γ-glutamyltranspeptidase activities indicates cholestatic liver diseases.
• A predominant rise in γ-glutamyl transpeptidase is observed in alcoholic or non-alcoholic fatty liver disease and infiltrating liver diseases.

Evaluation of Elevated Liver Enzymes

As stated in 4 and 5, the evaluation of elevated liver enzymes should be guided by both the clinical presentation and the pattern of injury. A systematic, stepwise approach to the evaluation and management of abnormal liver test results is recommended to optimize high-value care.

Diagnostic Approach

The study 6 suggests using a schematic approach that classifies enzyme alterations as predominantly hepatocellular or predominantly cholestatic to review abnormal enzymatic activity and the most common causes of enzyme alteration. The study 7 compares extensive testing and focused testing strategies for evaluating patients with elevated liver enzymes, and suggests that focused testing becomes the most cost-effective strategy when accounting for pre-test probabilities and prior evaluations performed.

Possible Causes and Next Steps

Based on the provided enzyme results, the possible causes and next steps would depend on the patient's clinical presentation, medical history, and physical examination. As mentioned in 3, a rise in liver enzymes is not necessarily indicative of a primary hepatic origin, and extrahepatic diseases often cause similarly increased serum activities. Further evaluation, including serologic testing and liver imaging, may be necessary to determine the underlying cause of the elevated liver enzymes.