By Dr. Jacobson, D.O.
A member wrote:
I’ve been doctoring a sharp, knife-like pain and burning in my sternum area for five months. My blood work shows high liver enzymes: AST [aspartate transaminase] of 561 and ALT [alanine transaminase] of 469. I've never consumed alcohol, smoked or taken drugs of any sort. In the last few days, my stools have been soft and a yellowish-orange color. All other tests—CT [computed tomography], MRI [magnetic resonance imaging], MRCP [magnetic resonance cholangiopancreatography], and ultrasound of my abdomen—showed nothing. Additional blood work results were good. Can you help me please?
Dr. Jacobson’s response: I summarize the history you’ve provided as follows: mid-chest pain; recent stool changes, soft and light in color; elevated liver (hepatic) enzymes with AST slightly higher than ALT; additional normal lab work; and no unusual radiology reports.
The first concern would be to address the chest pain and to rule out the most serious and immediate threats to your health. The pain’s duration—five months—and the sharp, stabbing character as a practical matter rule out a cardiac (heart) cause. It may, or may not, be related to the bowel and liver problems you describe. Most likely, it’s coming from the rib cage and sternum area; it's called atypical chest pain, though it’s the most common type.
The changes in stool are characteristic of someone who has a biliary system issue. Bile—which assists in the breakdown of fats—is dark green and gives the stool its brown color. Manufactured in the liver, bile is normally stored in the gallbladder. Released in response to a meal containing long-chain fats, bile moves in a duct that travels through the pancreas into the small intestines. Blockage of the bile ducts anywhere in this system can result in light-colored stools similar to your description.
Abnormal liver enzyme levels may also provide a clue as to the cause. ALT, AST and alkaline phosphatase are three of the most commonly-tested enzymes, but there are others, including bilirubin levels. The latter two are typically elevated when something outside the liver is blocking the bile system. However, if all other lab tests are normal, it’s most advantageous to look at the AST and ALT values.
You report that AST and ALT are only mildly elevated, and AST is slightly higher than ALT. In this scenario, causes that should be considered include:
- acetaminophen (generic for Tylenol) or other drug toxicity,
- autoimmune hepatitis, especially in females 30-50 years old
- non-alcoholic fatty liver disease, especially in presence of obesity, diabetes, elevated cholesterol and hypertension
- iron overload (genetic hemochromatosis)
- viral hepatitis—usually higher levels of ALT and AST in the acute stage
- ischemia (lack of blood supply to the liver)
- cirrhosis of the liver—usually from chronic alcoholism
- rhabdomyolysis (a by-product of massive muscle breakdown)
- hemolysis (breakdown of blood cells)
- Budd-Chiari syndrome (The liver veins can become blocked, preventing drainage. This syndrome can vary from extremely severe to no symptoms at all.)
- Wilson’s disease (A rare inherited disorder in which copper accumulates in the liver, brain and other organs. It may be accompanied by a brown ring, or copper deposits, along the edge of the cornea and may require a liver biopsy to diagnose).
- Other conditions outside the liver such as thyroid disease or celiac
The list of possible causes for elevated liver enzymes is long, and it can be difficult to ascertain the cause. The likely diagnosis usually becomes more apparent after standard lab tests and imaging such as you described.
As your diagnosis is still elusive, however, I would make sure that your physician(s) has taken a thorough look into possible auto-immune disorders and has considered performing a liver biopsy. The best route might be to take all of your records to a university-based hepatologist—a gastroenterologist who has sub-specialized in the study of disorders of the liver, pancreas, gallbladder and biliary tree.
DynaMed [Internet]. Ipswich (MA): EBSCO Information Services. 1995 - . Record No. T316452, Abnormal Liver Function Tests - Approach to the Patient; [updated 2018 Dec 02, cited West Chester, OH, May 21, 2020]. Available here. Registration and login required.
Vagvala, S.H. and O'Connor, S.D. (2018), Imaging of abnormal liver function tests. Clinical Liver Disease, 11: 128-134. doi:10.1002/cld.704