Can Gallstones Cause High ALT & AST Levels?

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Summary (key facts):

Gallstones are hardened deposits of bile that can form inside your gallbladder. Gallstones are very common, about 10-15% of people in the United States have gallstones (reference).

  • Under normal conditions (uncomplicated gallstone disease), gallstones are unlikely to cause elevated ALT or AST levels.
  • Gallstones can slip into the bile ducts (leading to an obstruction of the common bile duct), which can lead to elevated ALT, AST, and serum bilirubin.
  • Acute cholecystitis is another complication of gallstones that can lead to elevated ALT and AST levels.
  • Another scenario of elevated ALT and AST levels with gallstones is the presence of gallstones in abnormal sites such as the intrahepatic ducts.
  • Also, other causes of elevated ALT and AST levels should be considered with the uncomplicated gallstone disease.

Today, we will explain the possible scenarios of elevated ALT and AST levels with gallstone disease.

Too many people accidentally discover that they have gallstones during abdominal imaging.

Uncomplicated gallstones are divided into two main categories according to the presence of symptoms:

  • Asymptomatic gallstones (cholecystolithiasis): refers to the presence of gallstones or inside the gallbladder without any symptoms (biliary colic).
  • Symptomatic gallstones (uncomplicated gallstone disease): refers to the presence of biliary colics due to the presence of gallstones inside the gallbladder without complications.
  • Complicated gallstone disease: refers to the presence of complications related to gallstones:
    • Acute cholecystitis: acute inflammation and infection of the gallbladder due to an obstruction of the gallbladder neck.
    • Choledocholithiasis and acute cholangitis: when gallstones slip from the gallbladder opening into the bile ducts leading to obstruction and infection of the bile (cholangitis).
    • Mirizzi Syndrome: a rare complication where the gallstone inside the gallbladder duct (cystic duct) causes external compression on the hepatic ducts leading to obstruction of the bile outflow from the liver.

As a rule, the asymptomatic gallstones and the uncomplicated gallstone disease don’t cause elevated ALT and AST levels. The presence of elevated AST and ALT indicated either a complicated gallstone disease or an associated condition such as fatty liver, or chronic viral hepatitis.

Scenario (1): Asymptomatic gallstone or uncomplicated gallstone disease AND elevated ALT and AST:

We previously explained the terms (asymptomatic gallstones or cholecystolithiasis) and (uncomplicated gallstone disease).

The uncomplicated gallstone disease main symptom is biliary colics.

Biliary colics occur as a result of the contraction of the gallbladder (usually after eating) over the gallstone inside it. The contraction causes temporary obstruction of the gallbladder with subsequent biliary colic.

The temporary obstruction of the gallbladder often resolves a few hours later causing no complications (only the pain).

The detailed symptoms of biliary colic due to uncomplicated gallstone diseases are in the table below:

Biliary colic (Uncomplicated gallstone).Description
1. SiteUsually, The right upper quadrant of your abdomen
2. Spread– The pain may spread to the back of the right shoulder.– Also, it spreads to the epigastric area.
3. CharacterConstant builds up then disappeared gradually.
4. DurationAt least 30 minutes. It may last up to 6 hours.
5. Relation to food– Triggered by foods (especially fatty food and large meals.– However, it can start spontaneously.
6. NOT related to:Movement, bowel movements, or the passage of flatus.
7. NauseaOften Present, severe.
8- Commonly associated symptomsVomiting, sweating during the attack.
9. Unusual symptoms.– Heartburn and chest pain.– Bloating, fullness.– Early satiety.– Isolated epigastric pain.
10. Symptoms NOT associated:– Fever.– Jaundice.– Prolonged pain for more than 6 hours.– Extreme tenderness over the gallbladder (Murphy’s sign).– Vomiting of blood, blackish stool (PUD).

Learn more about Gallbladder pain and its mimics in-depth in this article.

What does it mean when you have elevated ALT and AST with uncomplicated gallstone disease?

Uncomplicated and asymptomatic gallstones DON’T cause elevation of the ALT and AST levels. The presence of elevated ALT and AST in such a case means either:

  • Development of complicated gallstone disease: such as acute cholecystitis, choledocholithiasis, or Mirizzi syndrome (see later).
  • Associated liver disease: the presence of gallstones with elevated ALT and AST liver enzymes isn’t always related to gallstones. Intrinsic liver diseases can be the cause and this is a common scenario.

If you have both gallstones and elevated ALT and AST levels, please call your doctor. Your doctor will evaluate you for the presence of any complications related to gallstones.

If no significant gallstone complications are found, your doctor will often investigate for other causes of elevated liver enzymes.

Commonly associated liver diseases that cause elevated liver enzymes include:

  • Nonalcoholic fatty liver disease (steatohepatitis).
  • Medications or toxins.
  •  
  • Chronic hepatitis C.
  • Chronic hepatitis B.
  • Alochol-related liver injury.
  •  
  • Hemochromatosis.

Less common causes:

  •  
  • Liver congestion (in people with heart diseases).
  • Malignant infiltration of the liver.
  • Autoimmune hepatitis.
  • Celiac disease.
  • Liver cirrhosis.
  • Wilson’s disease.
  • Alpha-1 antitrypsin deficiency.
  • Other viruses such as HEV, EBV, and CMV.

Among those causes, nonalcoholic fatty liver disease and medication-induced elevated liver enzymes are considered the two most common causes.

Scenario (2): Acute cholecystitis with elevated ALT and AST:

Acute cholecystitis refers to the syndrome of:

  • fever.
  • Right upper quadrant abdominal pain.
  • elevated white blood cell count.

The triad above is a result of obstruction of the gallbladder opening with subsequent infection and inflammation inside it due to gallstone.

Acute cholecystitis is the most common complication of gallstones.

Mild elevations of ALT and AST is often present with acute cholecystitis. But it is not common to see elevations in serum bilirubin levels. 

Acute cholecystitis pain is similar to biliary colics with the following differences (reference):

  • The gallbladder pain is often more severe and steady.
  • The biliary colic is often more prolonged (pain lasting for more than 6 hours usually indicates acute cholecystitis or bile duct stone).
  • Radiation to the right shoulder or back is more common.
  • Fever and ill-feeling are frequent.
  • Severe localized tenderness above the gallbladder area (The right-upper quadrant just below the rib cage). The severe local tenderness over the gallbladder area is Murphy’s sign (absent on uncomplicated biliary colic).
  • Nausea and vomiting are more common.

Acute cholecystitis is a severe condition (urgent medical attention is needed). Elevations in ALT and AST levels are

Scenario (3): gallstones-related biliary obstruction and cholangitis with elevated liver enzymes.

The impaction triggers two groups of symptoms:

  • Symptoms that are similar to acute cholecystitis.
  • Symptoms of bile outflow obstruction.

The following are differences from uncomplicated biliary colic:

  • Prolonged biliary colic (more than 6 hours).
  • More severe and constant pain.
  • Jaundice (a yellowish color of your skin and eye whites.
  • Dark urine (tea-colored).
  • Clay (pale grayish) stool.
  • Itching.
  • Fever also occurs.
  • Your doctor confirms the condition by laboratory tests (showing elevated bilirubin levels) and imaging (showing dilated common bile ducts).