Liver enzymes: No trivial elevations, even if asymptomatic

Brian Agganis; David Lee; Thomas Sepe

doi:10.3949/ccjm.85a.17103

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TABLE 1

Liver disease and associated liver enzyme elevations

Hepatocellular disease
(aminotransferase elevations predominate)

Common
Alcoholic liver disease
Autoimmune hepatitis
Chronic viral hepatitis
Genetic hemochromatosis (northern European ethnicity)
Medication toxicity (see Table 2)
Nonalcoholic fatty liver disease

Less common
Alpha-1 antitrypsin deficiency
Wilson disease

Cholestatic disease
(alkaline phosphatase, bilirubin, and gammaglutamyl transferase elevations predominate)

Common
Biliary obstruction (eg, gallstones)
Drug hepatotoxicity
Neoplasm
Primary biliary cirrhosis
Primary sclerosing cholangitis

Less common
Autoimmune cholangiopathy
Sarcoidosis

From Aragon G, Zounossi ZM. When and how to evaluate mildly elevated liver enzymes in apparently healthy patients. Cleve Clin J Med 2010; 77(3):195–204. doi:10.3949/ccjm.77a.09064.

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TABLE 2

Hepatotoxicity of selected drugs

Hepatocellular abnormalities
Acetaminophen—acute hepatitis
Allopurinol—granuloma
Azathioprine—veno-occlusive disease, nodular regenerative hyperplasia
Chaparral—portal inflammation with bile duct proliferation, lobar necrosis, and collapse
Diclofenac, other nonsteroidal anti-inflammatory drugs
Hydralazine—granuloma
Isoniazid
Methotrexate—fibrosis
Methyldopa
Mistletoe—hepatocellular injury
Nitrofurantoin—autoimmune-like disease
Quinidine—granuloma
Statins
Toxic alkaloid—veno-occlusive disease

Cholestatic abnormalities
Amoxicillin-clavulanate, other penicillin derivatives
Anabolic steroids—cholestasis, peliosis hepatis, neoplasm
Captopril
Carbamazepine
Chlorpromazine
Erythromycin estolate
Estrogens
Kava—hepatic necrosis, cholestasis, lobular hepatitis Oral contraceptives
Phenytoin—mononucleosis-like syndrome
Sulfa drugs

Drug-induced fatty liver
(with or without hepatocellular abnormalities)
Amiodarone —phospholipidosis
Anabolic steroids—cholestasis, peliosis hepatis, neoplasm
Cocaine—microvesicular steatosis
Corticosteroids
Jin Bu Huan—focal hepatic necrosis, steatosis, bridging fibrosis
Tetracycline
Valproic acid

Adapted from Aragon G, Zounossi ZM. When and how to evaluate mildly elevated liver enzymes in apparently healthy patients. Cleve Clin J Med 2010; 77(3):195–204. doi:10.3949/ccjm.77a.09064.