Differential Diagnoses for Mildly Elevated Transaminases

Primary Differential Diagnoses

The American College of Radiology suggests that Nonalcoholic Fatty Liver Disease (NAFLD) is the leading cause in developed countries, characterized by AST:ALT ratio <1, affecting up to 70% of obese patients and 90% of diabetics 1, 2
The American College of Radiology recommends considering Alcohol-induced liver disease, though typically presents with AST:ALT ratio >2, making this less likely unless alcohol consumption is moderate 1, 2
Medication-induced liver injury accounts for 8-11% of cases with mildly elevated liver enzymes and should prompt a thorough review of all prescribed medications, over-the-counter drugs, and herbal supplements 3
The American College of Radiology suggests that Chronic viral hepatitis B or C can present with this pattern, though typically causes higher elevations; however, negative hepatitis testing makes this unlikely 1

Autoimmune hepatitis typically presents with higher ALT elevations and elevated autoantibodies, but should be considered if other causes are excluded 1, 3
Hereditary hemochromatosis is an uncommon cause that requires screening with iron studies (ferritin, transferrin saturation) 1

Muscle disorders including recent strenuous exercise, rhabdomyolysis, or polymyositis can elevate AST more than ALT; check creatine kinase (CK) to exclude muscle origin 1, 2, 3
Thyroid disease (both hypothyroidism and hyperthyroidism) can affect liver enzymes and should be screened with TSH 1, 2, 3

Obtain detailed alcohol consumption history using AUDIT-C questionnaire, with ≥14-21 drinks/week in men or ≥7-14 drinks/week in women suggesting alcoholic liver disease 3, 4
Complete medication review including all prescribed drugs, over-the-counter medications, herbal supplements, and any recent medication changes 3, 4
Assess for metabolic syndrome components including central obesity (BMI), diabetes/insulin resistance, hypertension, and dyslipidemia, as these are major risk factors for NAFLD 1, 3

Abdominal ultrasound is the recommended first-line imaging test with 84.8% sensitivity and 93.6% specificity for detecting moderate to severe hepatic steatosis (>30% fat content) 1, 3

Your enzyme elevations are mild (<2× upper limit of normal), which typically indicates early or mild disease without immediate concern for severe hepatocellular injury 3, 4
Normal albumin, bilirubin, and INR indicate preserved liver synthetic function, suggesting no significant cirrhosis or acute liver failure 3
The AST:ALT ratio of 1.14 is slightly elevated but not the classic >2 ratio seen in alcoholic liver disease, making NAFLD or early alcohol-related disease most likely 1, 2