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What causes mildly elevated liver enzymes?

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Posted on Mon, 9 Jun 2014
Question: Started having mild elevations of liver enzymes AST, ALT, and GGT starting sometime late 2013 or early 2014 and still are elevated. Showed up on 1/15/14 bloodwork and previous bloodwork was 7/13 for a physical and all was normal then. By mild, AST and ALT around 60 and GGT about 100. Never have had high enzymes before and hadn't had any alcohol since 1/24/14. Had full bloodwork and ultrasound from a hepatologist a month or so ago at Emory Hospital in XXXXXXX and everything was normal except the high ALT and AST enzymes (didn't check GGT). Note that high dose purified fish oil seems to lower the alt/ast about 10-15 pts but has little to no effect on GGT. Hepatologist said the only other testing to consider if enzymes stay elevated is a biopsy.

My questions are:

1. How long does it take for mild enzyme elevations to cause permanent damage?
2. Could this be a residual effect of a slo-niacin I took in late 12/13-early 1/14? I only took 500 mg/day plus 125 mg of regular niacin in a Bcomplex when I was on it. Thought it might be the culprit but if it were the niacin, I'd think things would be back to normal by now. Maybe it was more toxic to my system than I realize??
3. What other type things can a biopsy show that the vast array of blood tests and ultrasound wouldn't show? Would it pinpoint the cause of high enzymes?? They did a bunch of blood tests I've never heard of before. What about other things to troubleshoot before going a liver biopsy route??
4. How accurate is biopsy? Couldn't the needle pick up tissue in an area of liver not inflammed?
5. I've felt terrible for 25-30 yrs. All kinds of allergy treatments to no avail. Is it possible there could be some issue with liver from earlier in life that maybe has caused me to feel bad ie: facial pressure, out of it feeling etc. Just asking as I know liver filters blood and maybe it hasn't been efficient for many years causing my symptoms?
6. I've had two lipid peroxide blood test since 1/14. Both showed very high oxidative stress. This is during the time I've had the elevated enzymes. I've read that high GGT can increase oxidative stress (catabolize glutathione) which is the body's natural antioxidant defense mechanism; my blood tests show this to be true in my case. Hence, the high GGT is a concern for more than just the liver. However, I'm at a loss for what may be causing it. Doing a biopsy seems a little premature unless I have the confidence it will tell me what's going on ie: both liver condition and cause of enzyme elevation.
doctor
Answered by Dr. Ashish Verma (14 hours later)
Brief Answer:
biopsy is 100% accurate

Detailed Answer:
Hi,

I read your query and understand your concern.

The liver usually has a very large reserve. Its only when its almost damaged more than 60-70%, the liver profile test gets deranged. Also alcohol is known to damage the liver. Though you have stopped its intake since four months, it all depends upon the extent of damage that has already been caused. Also, during healing phase the enzymes might get elevated more, i.e. more repair = more enzymes. So it might take a couple of months more before the enzymes level gets normal.

Now, coming to your specific queries-

1- Mildly elevated enzymes level usually don't signify permanent damage. There is no fixed period also for it. It all depends upon the cause and the persistence of the cause, the toxicity level of the disease causing factor.

2- Yes, niacin is known to cause hepatotoxicity, as a rare complication, but that is on prolonged intake, especially with sustained release preperations, and at dose >500mg/day (which you were taking). So its possible, that the niacin and your alcohol might have acted synergistically to cause more damage, than what they would had caused if taken alone. But this will need biopsy to confirm.

3- Biopsy is the gold standard. It shows the exact state of affairs in a tissue. It will tell the exact extent of damage, the exact type if damage, the exact severity of damage, and the possible causes for the same. The enzymes usually tell the reserve that is left as a result of the disease. Also, biopsy provides tissue to perform certain special staining, to help reach a diagnosis.

4- yes there is a rare possibility that the biopsy may miss the diseased tissue, but the depth of the tissue taken for biopsy is about 3-5cm, so chance of missing something is very rare. Also biopsy can be taken from multiple sites, to improve accuracy to 100%.

5- Allergy is not related to your liver damage. But the medicines that you might have take over so many years for those allergies, might had contributed to the liver damage, via their hepatotoxic effect, if any. Liver doesn't filters the allergens, its a hypersenstivity reaction, that can be for many things, that can even have a local effect, even before it gets into the blood to reach liver.

6- GGT is not specific to the liver, it is raised in disease of various organs. Liver is a majour body's natural antioxidant defense mechanism. And as your liver is compromised, so you have a high oxidative stress.

In my opinion, as all your other tests have been inconclusive, so biopsy is the only option left now, to get to a diagnosis. But as your enzymes are only mildly raised, so you may wait for some time, and repeat the liver profile, to see if its increasing or decreasing. If its increasing, then biopsy is strongly recomended.

Hope, i have been helpful.

Regards
Dr. Ashish Verma
Above answer was peer-reviewed by : Dr. Vinay Bhardwaj
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Follow up: Dr. Ashish Verma (11 hours later)
I will follow-up with hepatologist if the next blood chemistry hasn't come down. Had another couple of questions:

1. I've read the DHA in fish oil is good for reducing liver inflammation. Also read that black coffee has protective effects on the liver. Is there clinical evidence either or both of these are good for liver? As noted above, I'm pretty sure the omega 3 was responsible for bring the ALT and AST down 15-20 points on the last blood tests. The omega 3 doesn't seem to affect the GGT. If I hadn't gone to AnyLab test on my own dime, I wouldn't even know I had the high GGT as Dr's don't check.
2. Regarding how rotten I've felt for many years (30+ and I'm 53), is it plausible that liver might never have been functioning quite right even though I've always had good blood chemistry until the last few months?
3. Is there any other supplement/foods I can consume that will maximize protection of liver and possible liver enzyme reduction ie: Vit E, C, omega 3, etc.? Note that I exercise 7 days/week for about 30-45 mins/day.
4. How long before I can resume full exercise activities if I end up having biopsy? What about going back to work (nothing strenuous)?
doctor
Answered by Dr. Ashish Verma (2 hours later)
Brief Answer:
GGT is not specific for the liver

Detailed Answer:
Hi,

1- As i had told in my previous reply that GGT is not specific for the liver, it it raised in disease of various other organs. So maybe due to this reason your hepatologist could had ignored it. ALT is more specific for alcoholic liver damage.

And regarding clinical evidence of DHA and black coffee, there are only a few studies that have been done and that too were not of very robust. Also, these studies have high chances of being biased as they all are usually sponsored by the big manufacturers to help promote their products. So I would suggest that you exercise some caution while interpreting their results.

And yes, they both are rich in antioxidants, even omega 3, but take them in moderation, as excessive intake can even have harmful results.

2- Again as told in the previous reply, that liver has a very huge reserve, and it can maintain its function pretty well even its damaged by 60-70%. It's only when its damaged more, the blood chemistry starts getting deranged.

3- There are many foods/supplements to improve your liver functions. All green leafy vegetables, fish, fruits that are rich in antioxidants will do the work. And yes, you can even take Vit E, C, omega 3, etc. but dont exceed their daily recomended dose. Also various herbal preperations are available, like those of Himalaya company (by the name of Liv 52) which is available in your USA also. Its herbal, so no side effects.

4- After biopsy, you may resume your full exercise from the next day itself, provided there was no complications during the procedure, like excessive bleeding. If its there, then you need to wait for a day more.

Regards
Dr. Ashish Verma
Above answer was peer-reviewed by : Dr. Prasad
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Dr. Ashish Verma

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What causes mildly elevated liver enzymes?

Brief Answer: biopsy is 100% accurate Detailed Answer: Hi, I read your query and understand your concern. The liver usually has a very large reserve. Its only when its almost damaged more than 60-70%, the liver profile test gets deranged. Also alcohol is known to damage the liver. Though you have stopped its intake since four months, it all depends upon the extent of damage that has already been caused. Also, during healing phase the enzymes might get elevated more, i.e. more repair = more enzymes. So it might take a couple of months more before the enzymes level gets normal. Now, coming to your specific queries- 1- Mildly elevated enzymes level usually don't signify permanent damage. There is no fixed period also for it. It all depends upon the cause and the persistence of the cause, the toxicity level of the disease causing factor. 2- Yes, niacin is known to cause hepatotoxicity, as a rare complication, but that is on prolonged intake, especially with sustained release preperations, and at dose >500mg/day (which you were taking). So its possible, that the niacin and your alcohol might have acted synergistically to cause more damage, than what they would had caused if taken alone. But this will need biopsy to confirm. 3- Biopsy is the gold standard. It shows the exact state of affairs in a tissue. It will tell the exact extent of damage, the exact type if damage, the exact severity of damage, and the possible causes for the same. The enzymes usually tell the reserve that is left as a result of the disease. Also, biopsy provides tissue to perform certain special staining, to help reach a diagnosis. 4- yes there is a rare possibility that the biopsy may miss the diseased tissue, but the depth of the tissue taken for biopsy is about 3-5cm, so chance of missing something is very rare. Also biopsy can be taken from multiple sites, to improve accuracy to 100%. 5- Allergy is not related to your liver damage. But the medicines that you might have take over so many years for those allergies, might had contributed to the liver damage, via their hepatotoxic effect, if any. Liver doesn't filters the allergens, its a hypersenstivity reaction, that can be for many things, that can even have a local effect, even before it gets into the blood to reach liver. 6- GGT is not specific to the liver, it is raised in disease of various organs. Liver is a majour body's natural antioxidant defense mechanism. And as your liver is compromised, so you have a high oxidative stress. In my opinion, as all your other tests have been inconclusive, so biopsy is the only option left now, to get to a diagnosis. But as your enzymes are only mildly raised, so you may wait for some time, and repeat the liver profile, to see if its increasing or decreasing. If its increasing, then biopsy is strongly recomended. Hope, i have been helpful. Regards Dr. Ashish Verma