What is Transaminitis?
The function of the liver is to break down nutrients and keep the body safe from toxins. Enzymes in the liver are called as transaminases which help in carrying out this process. The excess of enzymes present in liver starts moving into the bloodstream.
Transaminases are set of two enzymes in the liver ‘Alanine transaminase (ALT) and ‘Aspartate Transaminase’. Transaminitis directly does not cause any disease or harmful effects in the body. However, transaminitis is one of the severe symptoms/cause of many liver diseases like hepatitis.
Various diseased conditions lead to increased transaminases enzyme level. These conditions include:
Fatty Liver Disease: Liver contains some fats, but the excess deposition of lipids is harmful and is called fatty liver disease. It is associated with symptoms of pain and fatigue.
Viral hepatitis: transaminitis is associated with viral hepatitis which is hepatitis B and hepatitis C.
Medications & Supplements: Some of the medicines also have the side effects of causing transaminitis. Some medicines that cause transaminitis include:
- OTC medicines like acetaminophen, Ibuprofen
- Statins like Lipitor
- Cardiovascular drugs like amiodarone
- Cyclic antidepressants
Some supplements also cause transaminitis which include Vitamin A. Intake of some herbs also leads to transaminitis, e.g. ephedra, Senna, skullcap etc.
HELLP Syndrome: This is one of the rare causes of transaminitis which occurs in women during pregnancy. It is associated with preeclampsia and is also accompanied by high blood pressure.
Genetic diseases: Some of the genetic disorders are also associated with transaminitis. These diseases include:
- Celiac disease
- Wilson’s disease
- Alpha-anti trypsin deficiency
Non Viral hepatitis: This includes hepatitis due to alcohol and autoimmune hepatitis. Alcohol hepatitis as the name suggests is hepatitis due to a large intake of alcohol usually over several years
Autoimmune hepatitis, on the other hand, is regarded as a genetic disorder.
Viral Infections: Some of the viral infections that lead to transaminitis include:
- Infectious mononucleosis
Liver cirrhosis: Liver cirrhosis is characterised by scarring of the liver tissues caused by alcohol intake or hepatitis. Transaminitis also accompany liver cirrhosis.
Liver cancer: Cancer of liver cells is also characterised by transaminitis. Although cancer in liver occurs rarely, It usually happens through metastasis which is spread of cancer from nearby organs.
Pancreatitis: This is associated with inflammation in the pancreas which may result in the organ damage. The causes of this include alcoholism or gallstones. The elevated level of Transaminitis is one of the Signs of Pancreatitis.
Some of the symptoms of transaminitis include:
Jaundice: Jaundice is characterised by yellow skin, mucous membrane and white portion of the eye. Jaundice is also accompanied by light-coloured stools and dark yellow urine. Some of the other symptoms of jaundice include fatigue, tiredness, weakness, pain in the abdomen, muscle pain and loss of appetite.
Itching of the skin: Itching is another sign that occurs locally on the skin and is one of the significant symptoms of transaminitis.
Swelling: Edema commonly occurs in case of liver diseases and is associated with increased liver enzyme levels in the body. The swelling is frequently found in feet, ankles, and legs.
Disease-associated symptoms: Apart from the general symptoms, there are symptoms which are specific to the diseases. These include:
- Fatty Liver disease: This is characterised by fatigue, pain in the abdomen and large size of the liver
- HELLP syndrome: This is marked by fatigue, stomach pain, nausea, vomiting, pain in the abdomen, bleeding, swelling, vision issues, pain while breathing deeply etc.
- Infectious mononucleosis: This is accompanied by swollen tonsils and lymph nodes, fever, headache, sore throat etc.
- Celiac Disease: This is characterised by symptoms like loss of body weight, bloating, tiredness and anaemia.
- Pancreatitis: Pancreatitis leads to nausea, vomiting, and pain in the upper abdomen area.
Diagnosis of Transaminitis:
As the causes of the increased enzyme levels in the liver are varied. The diagnostic tests depend on the signs and symptoms the doctor observes in the patient. Diagnosis includes determining the levels of the two enzymes ALT and AST in the body.
ALT enzyme is only present in the liver while AST enzyme is also present in other body parts including skeletal muscles. Therefore, measuring the levels of ALT is one of the most important criteria.
However, in some instances, the ratio of ALT and AST is also taken in to count. E.g. ratio higher than 2 indicates alcoholic liver disease while a ratio of less than 1 is associated with the Nonalcoholic liver disease.
Similarly, a ratio of greater than 4 may suggest Wilson’s disease. Following are the diagnostic tests used for transaminitis:
Patient and family history:
If the patient is alcoholic, it could be the case of alcoholic fatty liver and below tests should be further done for validation.
- AST and ALT ratio test
- Gamma-glutamyl transpeptidase levels
If the family history tells about hemochromatosis, then tests should be done to detect the iron and ferritin levels in blood serum. It also includes testing of the iron binding capacity of the cells.
In case the patient has recently travelled from an endemic country, or the person had some sexual contact or drugs etc. then the patient needs to be checked for hepatitis B. Hepatitis B surface antigen B test can be done to confirm this. This test checks for the presence of antigens on the hepatitis B.
In case the person had a viral infection, drug use or blood transfusion etc. then the person might be suffering from hepatitis C and should be tested for hepatitis C antibodies.
The person should also be checked and interrogated if he has been using any herbal medicine for some time.
In case there are metabolic disorders like increased triglycerides/glucose levels or increased circumference. In such cases, lipid profile, glucose levels, and ultrasonography needs to be done
Women with auto-immune disorders can be tested using tests which include serum protein electrophoresis, antibody to liver/kidney microsomal test and smooth muscle antibody test.
Patients with age lesser than 40 years and having neuropsychiatric symptoms, dark rings that encircle iris of the eye (Kayser Fleischer) might be suffering from Wilson’s disease and they should be tested for Serum ceruloplasmin level.
A person having abdominal pain and diarrhoea could be suffering from Celiac disease and should be tested for Tissue transglutaminase antibodies level.
If there are signs of hypo/hyperthyroidism, then TSH (Thyroid stimulating hormone) level in the person needs to be checked.
The complete diagnosis of this includes analysis of the patient and family history. Ruling out the options using diagnostic tests should be used to diagnose the cause effectively and then start the appropriate treatment. The person should be evaluated and re-evaluated periodically for the levels of transaminase levels.
If the levels of the enzyme do not change after monitoring of 6 months, then a liver biopsy of the patient should be considered.
Treatment of Transaminitis:
It is important to note that transaminitis is not a disease, but it is a consequence that results from the disorders discussed above.
The treatment of this would depend on the diagnosis of the disease which has resulted in the increased levels of transaminases, and the treatment should be carried out accordingly.
Treatment will include abstinence from fatty, spicy and oily food.
In case there are medications, which have increased liver enzymes then these medicines should be stopped, and alternative medications should be discussed with the doctor.
In case of any liver diseases, alcohol intake should be strictly prohibited.
Cardiovascular drugs have also been found to cause liver damage and hence increase transaminases level. Statins are one class of drugs used for the treatment of cholesterol which has a side effect of causing damage to the liver.
This has been proved in the clinical trials that these are one of the most significant causes of liver damage. If the patient is susceptible to damage due to Statins, they should get them shifted to other class of drugs.
In such situations, it is essential to do a cost-benefit analysis which is used to see if the benefits of the drug are higher compared to the side effects or the harm that the drug causes to other organs. A doctor should also search for any alternative medicine that can be used to treat without causing any damage to the other organs.
In case of ischemia or lack of oxygen after cardiac surgery, it is vital to restoring oxygen level to the body.
Abnormalities such as hypoglycemia, hypokalemia should be corrected. Fluid levels in the body should be maintained to 75% of the requirement to prevent oedema
Blood count should be monitored as some children develop anaemia in case of liver failure.
Patients with liver failure are also prone to bacterial infection and should be treated with antibiotics. They should also be tested for herpes simplex virus and should be treated after that
Gastric acid supplements should be given along to prevent gastric bleeding.
The lifestyle of the patient should be assessed for the required change.
Transaminitis is not a disease in itself but a symptom of many other conditions, so the level of these enzymes should be maintained at an optimum level.