High Liver Enzymes: Causes, Symptoms, and When to Worry

You've received your blood test results, and next to ALT or AST, there's an arrow pointing up. High liver enzymes. Those words can sound scary—does this mean your liver is failing?

Take a deep breath. Elevated liver enzymes are incredibly common, and in most cases, the cause is identifiable, treatable, and doesn't mean permanent liver damage. This guide will help you understand what liver enzymes are, why they might be elevated, and what to do next.

Normal ranges (varies by lab):

• ALT: 7-56 U/L
• AST: 10-40 U/L

Your liver contains thousands of enzymes—proteins that help chemical reactions happen. When we talk about "liver enzymes" on blood tests, we're usually referring to two specific ones:

ALT (Alanine Aminotransferase)

• Found primarily in the liver
• Very specific to liver injury
• When liver cells are damaged, ALT leaks into the bloodstream
• Elevated ALT almost always means liver involvement

AST (Aspartate Aminotransferase)

• Found in the liver, but also in:
  • Muscles (including the heart)
  • Kidneys
  • Brain
• Less specific than ALT
• Elevated AST can come from liver OR muscle injury

The De Ritis Ratio: AST/ALT

Comparing AST to ALT gives diagnostic clues:

1. Non-Alcoholic Fatty Liver Disease (NAFLD) - MOST COMMON

This is the #1 cause of elevated liver enzymes in Western countries.

What it is: Fat accumulation in the liver in people who drink little to no alcohol

Who gets it:

• Overweight or obesity
• Type 2 diabetes or prediabetes
• High cholesterol
• Metabolic syndrome

Liver enzyme pattern:

• ALT higher than AST (usually)
• Mild to moderate elevation (1.5-3x normal)
• ALP may be mildly elevated

Good news:

• Often reversible with weight loss
• Lifestyle changes can normalize enzymes
• Most people don't progress to serious liver disease

2. Alcohol-Related Liver Disease

What it is: Liver damage from excessive alcohol consumption

Pattern:

• AST higher than ALT (often 2:1 ratio)
• Both enzymes elevated
• GGT (another enzyme) usually also elevated

Amount that causes elevation:

• Varies by individual
• Some people develop problems with moderate drinking
• Others can drink more without issues
• Women are more susceptible than men

Good news:

• Abstinence often leads to improvement
• Enzymes can normalize within weeks to months of stopping alcohol

3. Medications and Supplements

Many medications can elevate liver enzymes:

Acetaminophen toxicity is serious:

• Overdose can cause acute liver failure
• Keep daily dose under 3,000mg (less if you drink alcohol)
• Never take more than directed

Herbal supplements aren't automatically safe:

• "Natural" doesn't mean harmless for your liver
• Bodybuilding supplements can cause liver injury
• Some weight loss supplements are contaminated

4. Viral Hepatitis

Hepatitis A, B, and C can all cause elevated liver enzymes.

Acute viral hepatitis pattern:

• AST and ALT both very high (often 10-100x normal)
• AST and ALT roughly equal
• Bilirubin often elevated (causing jaundice)

Chronic viral hepatitis:

• More mild elevation (2-5x normal)
• May fluctuate over time
• Requires antiviral treatment for hepatitis B and C

Get tested if:

• You have risk factors (shared needles, unprotected sex, medical procedures in high-risk areas)
• You were born between 1945-1965 (hepatitis C screening recommended for all)
• You have elevated enzymes with no clear cause

5. Autoimmune Hepatitis

What it is: Your immune system attacks your liver

Who gets it:

• More common in women
• Can occur at any age
• Often associated with other autoimmune diseases

Pattern:

• Elevated AST and ALT
• Elevated immune globulins
• Positive autoantibodies on testing

Treatment:

• Immune-suppressing medications
• Usually responds well to treatment

6. Hemochromatosis (Iron Overload)

What it is: Genetic condition causing excess iron absorption

Pattern:

• Elevated liver enzymes
• High ferritin (iron storage)
• High transferrin saturation
• May cause diabetes, skin discoloration, joint pain

Treatment:

• Therapeutic phlebotomy (regular blood removal)
• Excellent prognosis if treated before organ damage occurs

7. Celiac Disease

What it is: Gluten sensitivity causing immune reaction

Connection to liver:

• Up to 40% of people with celiac have elevated liver enzymes
• Gluten exposure triggers inflammation that affects the liver
• Enzymes usually normalize on gluten-free diet

8. Less Common but Important Causes

• Wilson's disease: Copper accumulation (rare, genetic)
• Alpha-1 antitrypsin deficiency: Genetic protein deficiency
• Budd-Chiari syndrome: Blocked hepatic veins
• Liver cancer: Usually in setting of cirrhosis
• Heart failure: "Congestive hepatopathy" from backup of blood

Your doctor may order these alongside ALT/AST:

Elevated liver enzymes themselves aren't an emergency, but certain situations need prompt attention:

Seek Prompt Care For:

• ALT or AST over 1,000 U/L (suggests acute injury)
• Enzyme elevation with jaundice (yellowing of skin/eyes)
• Enzyme elevation with severe abdominal pain
• Enzyme elevation with confusion or extreme sleepiness
• Enzyme elevation with easy bruising or bleeding
• Known acetaminophen overdose
• Known liver disease with sudden worsening

Schedule Prompt Follow-Up For:

• Any unexplained liver enzyme elevation
• Enzymes that are rising over time
• Enzyme elevation plus other abnormal liver tests
• Risk factors for liver disease (alcohol use, hepatitis exposure, etc.)

Elevated liver enzymes are a clue, not a diagnosis. Your doctor will investigate:

Essential Initial Tests

Additional Tests (as indicated)

• Ultrasound or other imaging: Look at liver structure, bile ducts
• Iron studies: Screen for hemochromatosis
• Celiac antibodies: Screen for celiac disease
• Autoimmune markers: ANA, ASMA, anti-LKM
• Ceruloplasmin: Screen for Wilson's disease
• Alpha-1 antitrypsin level: Genetic deficiency
• FibroScan: Measures liver stiffness (fibrosis)

Treatment depends entirely on the underlying cause:

For Fatty Liver (NAFLD/MAFLD)

Lifestyle changes are first-line:

• Weight loss: 7-10% loss can significantly improve fatty liver
• Exercise: At least 150 minutes per week
• Diet: Mediterranean style, limit sugar and refined carbs
• Avoid alcohol: Even modest amounts can worsen fatty liver
• Control diabetes and cholesterol

Good news: Most people see enzymes improve within 3-6 months of lifestyle changes.

For Alcohol-Related Liver Disease

• Stop drinking alcohol: Complete abstinence is ideal
• Nutritional support: Many people with alcohol-related liver disease are malnourished
• Vitamin supplements: Especially B vitamins

for Medication-Induced Elevation

• Stop the offending medication: If possible
• Find an alternative: Work with your doctor
• Monitor: Enzymes usually normalize within weeks to months

For Viral Hepatitis

• Hepatitis A: Supportive care, usually resolves on its own
• Hepatitis B and C: Antiviral medications can control or cure the infection

For Autoimmune Hepatitis

• Imunosuppressants: Prednisone, azathioprine
• Lifelong monitoring: But usually well-controlled

While waiting for your appointment:

1. Review Your Medications and Supplements

Make a complete list of:

• Prescription medications
• Over-the-counter drugs (especially pain relievers)
• Supplements and vitamins
• Herbal remedies
• Protein powders or workout supplements

Don't stop anything without talking to your doctor—some medications can't be stopped abruptly.

2. Be Honest About Alcohol

Your doctor needs accurate information to help you. Track:

• How many drinks per week
• Typical pattern (daily vs. binge drinking)
• How long you've been drinking at this level

3. Assess Your Risk Factors

For fatty liver:

• BMI over 25?
• Type 2 diabetes or prediabetes?
• High cholesterol?
• Waist circumference > 40 inches (men) or > 35 inches (women)?

For viral hepatitis:

• Any risk factors (shared needles, unprotected sex, tattoos, medical procedures abroad)?
• Born between 1945-1965 (hep C risk)?

For hemochromatosis:

• Family history of liver disease?
• Northern European ancestry?
• Diabetes, "bronze" skin color, joint pain?

4. Don't Panic, But Don't Ignore

• Most causes of elevated enzymes are treatable
• Your liver has remarkable regenerative capacity
• But do follow up—ignoring the problem allows progression

1. "What's causing my elevated liver enzymes?"
2. "How elevated are they—is this mild, moderate, or severe?"
3. "What additional tests do I need?"
4. "Do I need an ultrasound or other imaging?"
5. "Could any of my medications be causing this?"
6. "Do I need to stop alcohol completely?"
7. "How concerned are you about this?"
8. "What lifestyle changes do you recommend?"
9. "When should we recheck my levels?"
10. "Do I need to see a liver specialist (hepatologist)?"

Elevated Enzymes in Pregnancy

Causes:

• Fatty liver of pregnancy (serious)
• HELLP syndrome (serious)
• Preeclampsia-related liver involvement
• Normal pregnancy-related changes

Prompt evaluation is essential—some pregnancy-related liver conditions are emergencies.

Asymptomatic Elevation Found on Routine Testing

This is very common—your enzymes are elevated but you feel fine. Don't ignore it:

• Needs investigation to find the cause
• Many causes are silent until significant damage occurs
• Early intervention prevents progression

Persistently Normal After Initial Elevation

Great news! This suggests:

• The cause was temporary (viral infection, medication, etc.)
• No ongoing liver injury
• Continue monitoring as your doctor recommends

Elevated liver enzymes are a finding, not a diagnosis. They tell you something is irritating your liver, but additional testing is needed to identify the specific cause.

Most common scenarios:

• Fatty liver (most common, related to metabolic syndrome)
• Alcohol-related (second most common)
• Medication-induced (many possible culprits)
• Viral hepatitis (B or C)

The key is finding the cause:

1. Don't panic—most causes are identifiable and treatable
2. Get the recommended follow-up tests
3. Address the underlying cause
4. Make necessary lifestyle changes
5. Recheck to confirm improvement

Your liver is resilient and can regenerate, but it needs you to identify and remove whatever is injuring it. Work with your healthcare team, be honest about alcohol and medications, and commit to the lifestyle changes needed to support your liver health.

Related articles on WellAlly:

• Fatty Liver Disease: What You Need to Know
• Understanding Your Complete Metabolic Panel
• Alcohol and Your Liver: How Much Is Too Much?
• Hepatitis C: Complete Patient Guide