Elevated liver enzymes are a common scenario encountered by physicians in clinical practice. For many physicians, however, evaluation of such a problem in patients presenting with no symptoms can be challenging. Although alterations of liver enzymes could be a normal physiological phenomenon in certain cases, it may also reflect potential liver injury in others, necessitating its further assessment and management. 
What are liver enzymes and what does it mean with elevated liver enzymes?
Liver enzymes are proteins that speed up chemical reactions in our body. These chemical reactions include producing bile and substances that facilitates blood clot, breaking down food and toxins, and fighting infection.
Elevated liver enzymes often indicate inflammation or damage to cells in the liver. Inflamed or injured liver cells leak higher than normal amounts of certain chemicals, including liver enzymes, into the bloodstream, elevating liver enzymes on blood tests.
The elevated liver enzymes most commonly found are:
Alanine transaminase (ALT)
Aspartate transaminase (AST)
Alkaline phosphatase (ALP)
Gamma-glutamyl transpeptidase (GGT)
Elevated liver enzymes might be discovered during routine blood testing. In most cases, liver enzyme levels are only mildly and temporarily elevated. Most of the time, elevated liver enzymes don't signal a chronic, serious liver problem.
How are elevated liver enzymes treated?
Treatment depends on what is causing the liver enzymes to be elevated. About one-third of people with elevated liver enzymes will have normal liver enzyme levels after two to four weeks. If the liver enzymes stay high, more blood tests, or imaging tests such as ultrasound, CT scan or MRI should be carried out to find out the cause.
The challenge in treating elevated liver enzymes
Evaluation of abnormal liver enzyme levels in an otherwise healthy patient can pose a challenge to even an experienced clinician. It may not be necessary to pursue extensive evaluation for all abnormal test results, however, as it would expose many patients to unnecessary procedural risks and expenses. Conversely, failure to investigate mild or moderate liver enzyme elevations could mean missing the early diagnosis of potential life-threatening yet treatable conditions. 
CASE STUDY: Asymptomatic Patient With Abnormal Liver Test Results
(Please skip the following and jump to the discussion if the medical details are too much. Do not consume any herbs on your own without professional supervision.)
A 57-year-old male came to my clinic with no specific chief complaint in 11.2020. He was my patient once in 5.2019 complaining about abdominal bloatedness and smelly, runny stool but no further visits and treatment were carried out until he revisited more than a year later. In 1.2021, he revealed a blood test with elevated bilirubin, AST, ALT, GGT, CEA and Ca19. Since he was already visiting my clinic for 2 times and consumed herbal prescription, I request for more past blood test results to rule out the possibility of herb-induced liver injury. As it turned out, the patient had elevated liver enzymes since 2019 and the numbers kept rising.
SUBJECTIVE AND OBJECTIVE CONDITIONS
The patient initially came with no specific complaints about any physical or psychological conditions. He claimed to be generally well with an occasional disturbed sleep. Bowel movement is regular and smooth but he often felt gassy and the gas was smelly. He declined a history of chronic illness. A social drinker. The patient is a regular built Slovenia man, mild central fat but no general obesity.
In the TCM diagnostics, I observed pink tongue with thin white fur. His pulse is small and the movement of pulse is heavy and thick. The intestine pulse is small, kidney and bladder pulse is strong and thick, spleen pulse is heavy and thick with moderate power. [Read more: What Tongue Diagnosis can tell you] [Read more: Pulse diagnostic]
Prescription of herbs:
Hei Zhi Ma (black sesame), Di Gu Pi, Tu Fu Ling, Tao Ren, Chai Hu, Gan Cao, Sheng Jiang, Yi Mu Cao
The patient returned with no symtoms. Pulse dianostics showed the kidney pulse is not strong anymore but a deep hallowness. In the prescription, Tu Fu Ling and Tao Ren were removed, Hu Tao Ren was added.
The patient had a routine blood test and found higher sedimentation and liver enzymes but did not show the actual numbers. Further investigations were suggested. Herbs remained unchanged until blood test results are reviewed.
His latest blood test report showed elevated bilirubin, AST, ALT, GGT, CEA and Ca19. He was still asymptomatic. It is rather common in male patients that they do not express their concerns and needs with their physicans. Therefore I restart my interview of lifestyle and dietary habits, and request for previous medical reports. Later I relieved that he has been noticing elevated liver enzymes since 2019 and recently started consuming turmeric and cinnamon due to many health claims he found on the internet.
I instructed him to stop all unprescribed remedies, whether natural or chemical. Lifestyle and dietary adjustments were also suggested. Pulse diagnostics showed strong and suppressed liver pulse, strong and thick pulse in right “chi” position. [Read more: When you eat is just as important as what you eat] [Read more: Circadian Rhythms and the Chinese Medicine Body Clock]
Prescription of herbs:
Sheng Di Huang, Jin Qian Cao, Chai Hu, Gan Cao, Sheng Jiang, Yi Mu Cao, Yin Chen, Long Dan Cao
Prescription of herbs:
Sheng Di Huang, Da Huang (Sheng), Chai Hu, Gan Cao, Sheng Jiang, Yi Mu Cao, Yin Chen, Long Dan Cao
The patient’s symptoms were relieved. Pulse showed deep liver tension, both chi strong and slippery, spleen thick and overflows. Tongue is pink with dense light yellow fur at the back. Prescription unchanged and added Huang Bai.
Blood test showed a decrease in number in liver enzymes, but still abnormal. Pulse showed both chi strong, liver and spleen smoother than before. Tongue is pink with light yellow fur at the back.
Prescription of herbs:
Sheng Di Huang, Da Huang (Sheng), Zhi Zi (Shan), Da Qing Ye, Sheng Jiang, Bai Shao, Long Dan Cao, Huang Bai, Wei Ling Xian
Pulse showed left chi moderate strong and slippery, liver deep level strong.
Prescription of herbs:
Sheng Di Huang, Da Huang (Sheng), Zhi Zi (Shan), Da Qing Ye, Sheng Jiang, Bai Shao, Long Dan Cao, Tu Fu Ling, Yin Chen
All liver enzymes readings were normal.
The patient continued working for further improvement. By 8.12.2021, all liver enzymes remained normal, CEA and Ca19 normal, but cholesterol and LDL were high.
This case poses a couple of challenges in diagnosis and treatment. First of all, the patient came with very little verbal communication and provided very little details about his health condition and concerns. This is particularly common in Slovenia. Even though no formal studies in men’s medical adherance or help-seeking in TCM are found, there is a systematic review showing that men indeed seek help less often in mental health. As both mental health and TCM health prevention are more subtle and unnoticed forms of health issue, we could logically link the phenomena. Another obstacle for a clear and open communication in the TCM practice could be a problem of the understanding and acceptance of TCM. TCM remains unheard of or misunderstood with many Slovenians. This makes patients skeptical and unconfident about TCM treatment. [Read more: TCM vs Western Medicine] [Read more: Your Body as a Garden]
The second challenge is the result of the first. Since little details were provided, the regular TCM syndrome differentiation could be difficult. Syndrome differentiation is a commonly used methodology and practice in TCM guiding the diagnosis and treatment of diseases. The unique TCM diagnosis and treatment system requires a comprehensive analysis of a patient’s symptoms. But in the asymptomatic case, or if the patient is unwilling, unable to tell the symptoms, then the challenge of TCM diagnosis lays almost completely on the practitioner. In such case, the practitioner must pay extra attention to the non-verbal details like the appearance, smell, facial expression, logical questioning and most importantly tongue and pulse diagnostics.
In this case study, the pulse diagnostics is the key component that guides the whole treatment process. In his first visit, although a small pulse is noticed, and it usually indicates a deficiency or weakness, but the texture of the pulse and several locations showed contradictory findings. Practitioners must not jump too fast into any aggressive tonifying formula. In fact, a per made formula should be avoided or made as simple as possible. Certain herbs in the formula might not be best suited in the situation. Individualized prescription and periodic adjustments will provide the best flexibility and accuracy of herbs usage thus enhancing the effectiveness and reducing toxicity.
While modern medicine tends to eliminate subjectivity, TCM is about blending objectivity and subjectivity. The decision to go towards cleansing herbs rather than tonifying herbs is mostly the practitioner’s personal judgment based on experience. In the modern times, it is more likely to encounter an excessive type of patients rather than a deficient type of patient in the liver and kidney system, or at least a mixed pattern. The pure kidney Yin or Yang deficiency as described in ancient text is now extremely rare. The seeingly small pulse could indicate an extremely excessive toxins, particularly the dampness, suppressing the normal Qi and Blood flow. Therefore, it is important to also examine the texture of the pulse. Instead of the textbook description of slippery pulse, it is a lot more common to notice a thick pulse. Imagine a normal pulse is like water circulating inside the vessel, a thick pulse is honey or cruel oil inside.
The third and biggest challenge for managing elevated liver enzymes with TCM is the low medical adherence and compliance. As shown in this case study, the initial phase of treatment took 3 months, and the whole treatment could last for a year, sometime more. In real life practice, not every patients are suitable for the cleansing herbs right from the start, or some of them could have difficulties in the lifestyle an dietary adjustment. All these factors could delay the process or lower the effectiveness of treatment. There is no shortage of interest in alternative treatment, however, in my own clinic’s record, more than 80% of patients dropped out of treatment within the first 3 visits. The success of the case study is rare, but completely repetiable given the suitable guidance and treatment are followed. I hope by sharing this detailed case study (and a few more to come) could improve the understanding and confidence of TCM treatment among practitioners and patients.
Malakouti M, Kataria A, Ali SK, Schenker S. Elevated Liver Enzymes in Asymptomatic Patients - What Should I Do? J Clin Transl Hepatol. 2017 Dec 28;5(4):394-403. doi: 10.14218/JCTH.2017.00027. Epub 2017 Sep 21. PMID: 29226106; PMCID: PMC5719197.
Sagar-Ouriaghli I, Godfrey E, Bridge L, Meade L, Brown JSL. Improving Mental Health Service Utilization Among Men: A Systematic Review and Synthesis of Behavior Change Techniques Within Interventions Targeting Help-Seeking. Am J Mens Health. 2019 May-Jun;13(3):1557988319857009. doi: 10.1177/1557988319857009. PMID: 31184251; PMCID: PMC6560805.