What is the reason for my elevated liver enzymes and gamma GT?

Q. I have elevated liver enzymes and gamma GT with seronegative RA. Please help.

Answered by
Dr. Ajeet Kumar
and medically reviewed by Dr. Vinodhini. J
This is a premium question & answer published on Aug 22, 2020 and last reviewed on: Aug 21, 2023

Hi doctor,

My bloodwork has concerned me. I have elevated liver enzymes and high gamma GT. I also have seronegative RA, some joint pain and recently some nausea. I am currently on Vitamin D, Vitamin E, and Turmeric fish oil.



Welcome to icliniq.com.

Well you are right these test reports nonetheless are a concern to you as well to me (attachment removed to protect patient identity). Let us just sort out things one by one.

First of all your weight is slightly overweight. Your current body mass index (BMI) which is proportion of your weight to your height is 28.3, which is just 3.2 above the normal value of 25. So it is possible that fatty liver is partially contributing to your problem. But I doubt if it is the only explanation to your deranged liver enzymes unless we exclude the other potential causes of such elevation of your liver enzymes.

The potential causes of the elevated liver enzymes are alcohol-related liver dysfunction. Please mention if you take any alcohol and its quantity in a week time. Autoimmune hepatitis, which is another common entity and it is reasonable to think in your case given your past history of seronegative RA (rheumatoid arthritis). I would write some blood tests to exclude that.

Lastly, there is another set of disorders with an elevation of the liver enzymes namely Wilson disease (often has a family history of liver disease), alpha antitrypsin deficiency (with accompanying cough, asthma, sputum, and family history positive for the same), and iron overload called hemochromatosis.

Please do not get frightened reading all these unique and aberrant diagnosis, it is possible that you might have nothing except fatty liver disease, but I will write down a panel of investigation below, to exclude all above possibilities, to be on the safe side. There is no special clinical or examination findings which can justify the above diagnosis, except the blood test which I write down below. HbsAg negative is a good sign, and it suggests against the diagnosis of acute, or chronic hepatitis B infection. So it is unlikely that you have hepatitis B infection. HbCore total suggest that you have prior exposure to hepatitis B virus, possibly cured with treatment or spontaneously. I will suggest you some more investigation to be sure that you do not have active hepatitis B infection. HAV IgG (antibody of hepatits A virus) suggest old infection. There is specific test i.e. IgM to detect the hepatitis B infection currently.

So to summarize, there are some more tests required to establish the reason for elevated liver enzymes. I can understand that you must be anxious, that you are supposed to get another cycle of investigations, but this only how we can establish the cause of this, and can then be able to guide you optimal plan of action.

Kindly stop taking vitamin D and vitamin E if there are no significant deficiency in the blood tests. You can carry with fish oil.

Let me know some more information as well. Did you use any herbal medications, contraceptives, steroids, antibiotics in the last couple of weeks or months? Are any painkillers or steroid use for controlling your seronegative RA? Or current or past use of Methotrexate?

The Probable causes:

Hepatitis A infection. Hepatitis E infection. Chronic hepatitis B infection. Autoimmune hepatitis. Drug induced liver disease. Systemic disease RA with deranged liver enzymes.

SLE (systemic lupus erythematosus).

Investigations to be done:

Complete blood count and ESR (erythrocyte sedimentation rate). ANA (antinuclear antibody), ASMA (anti-smooth muscle antibody), Anti LKM-1 (liver kidney microsome)antibody. Serum ceruloplasmin. Alpha antitrypsin 1 levels. Serum ferritin, serum iron, transferrin saturation. Hepatitis B DNA quantitative, HAV (hepatitis A virus) IgM, HEV (hepatitis E virus) IgM. Ultrasound abdomen with color doppler of liver vessels. Fibroscan of the liver (transient elastography).

Regarding follow up:

Let me know the additional information which I have asked, as I can short list the investigations.

Thank you doctor,

I do not drink alcohol and take only on occasions. Perhaps 10-15 drinks a year. I have attached bloodwork taken two weeks ago. I never took MTX. I have only taken Plaquenil and Sulfasalazine in the past. I feel my liver problems started back when I had to get my gallbladder removed. I caught jaundice. I have had liver bloodwork a bit normal/a bit high.

Bloodwork done when I went into labor in January was fine. All normal. I have an appointment with a hepatologist on Friday. However, I did not know if this bloodwork is a cause for serious concern where I should go to the emergency room today. These exams were provided by my rheumatologist.

In 2016, an ultrasound was performed and I was told I have a fatty liver and similar liver bloodwork was done. Things were a bit elevated at the time but with natural vitamins went back to normal levels.



Welcome back to icliniq.com.

I reviewed all tests you uploaded (attachment removed to protect patient identity).

It was expected to have raised liver enzymes when one have an operation in the vicinity. But they usually come within normal in subsequent weeks. This would not be the cause of your current liver enzymes derangements. You need not to rush to anywhere with this liver enzyme pattern, just need to get the relevant workup and things are going to be fine very soon once we make a diagnosis and start you on some targeted treatment.

Since it is very difficult to establish a diagnosis just based on only liver function tests, instead it requires more than that, that is why I am unable to offer you any specific treatment right now. But anyway, these are not an alarming elevation of liver enzymes, which are usually those in range of thousands, which are the ones that require urgent hospital referral and potential admission.

I hope this helps.

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