Episode #389: Your Liver Enzymes Are Elevated — But It Might Not Be Your Liver

23:13Dr. Austin Baraki:But that's still not going to be in my first pass here. And interestingly, you know, we've been pretty focused so far on the labs from 2021, 2022, I think was, you know, when the initial visit to Asia happened and the subsequent follow-up, but you also provided me some labs going further back, as far back as 2010. And interestingly, when I look back across that whole lab trend, even back in 2010, he had an ALT and an AST level in the 40s. And one of the tricky things, this is something I come across in practice all the time, is that lab reference ranges for those transaminases are pretty variable between institutions.

23:51Dr. Austin Baraki:but real, you know, hepatology purists will say that an ALT of 40 is not normal. It might be very mildly elevated on that reference range. It doesn't get my attention nearly as much as an ALT level of a thousand, but that person's in acute liver failure, much more likely, right? But an ALT of 40 is not normal. And so the true, like if you look at their professional society is called the American Association for the Study of Liver Diseases or the AASLD. And they have pretty stringent cutoffs for what normal transaminases should be before you start worrying about some form of hepatocellular injury, most commonly under-recognized as fatty liver disease.

24:33Dr. Austin Baraki:Even somebody with an ALT of like 28, 29, it might be in a territory where they're already starting to show signs of this. So now when I look all the way back to 22, this is like over a decade ago that he had some abnormalities at that point. They kind of smoldered, persisted a few years later, got a little bit better. Now they're getting worse again. And so with this degree of chronicity, I am much more suspicious, again, of something like fatty liver disease or less likely at this point, some form of like autoimmune kind of disease that's like smoldering over time that can kind of relapse and remit.

25:06Dr. Austin Baraki:But that would be much less likely at this point without other features that I'd be looking for in a patient like this. So that's kind of my updated thought process based on the new labs you gave me and my persistent differential diagnosis that I am not wavering from at the moment. I'm sticking with my guns at this point. And so how would I talk about this with the patient? Well, first I would ask him like what his understanding is of what's going on to get a sense of where is he starting from? What has he been told? What is he most worried about? and also by listening carefully to the way that he describes his understanding, I can also elicit and get a sense of like, what's his level of health literacy, his level of education, and like, what level can I speak to him about?

25:50Dr. Austin Baraki:Or what level can I match him at when speaking about this topic? If he speaks to me in much more medical terms, I might glean that maybe he has a background and we can speak at a different level. But ultimately, my concern is that we have some sort of a long-term issue that has been affecting his liver. And now it really seems to be declaring itself a bit more. So I can see some signs of it going back over a decade ago, but it was really, really mild. I wouldn't fault anybody for not, you know, making a big deal about it back then. It actually started to look a little bit better, but now it's like really starting to manifest.

26:24Dr. Austin Baraki:I would say this is still not a time to panic. He is not at imminent risk right now of something severe happening in the short term, because that might be a big source of concern in somebody's mind. We still have time to figure this out. And this is something that we will get to the bottom of that. I would also kind of convey that sense of confidence. I can't say that I've had a scenario like this come up where it's just like, oh, well, you're just like never able to figure it out. There is something going on here. There will be an identifiable cause that we can detect. It's just going to be a little bit of time.

26:57Dr. Austin Baraki:And fortunately, we do have that time to get there. So that would be the way I would talk about it with him.

27:01Dr. Jordan Feigenbaum:Yeah, it seems like on the differential, you've moved past the viral hepatitis that he seems he's negative for that. You still have this non-alcoholic fatty liver disease or fatty liver disease on the differential, although it's less likely given his body habitus. He's very lean and appears to be active. The drug-induced liver injury still on the differential, especially if he's not really reporting all of the things that he's taking, especially in an active population, particularly like gym rats, you might be suspecting a supplement that's either contaminated or even just has the risk of causing this anyway.

27:39Dr. Jordan Feigenbaum:So, synephrin and caffeine, for example, has been directly associated with severe rhabdomyolysis, which can cause some elevated transaminases. Ephedra, which has been banned, is also linked to rhabdomyolysis, sometimes fatal cases. Many oral anabolic androgenic steroids can be hepatoxic. Many herbal dietary supplements, things like hydroxycut, garcinia cambogia, and Herbalife supplements have been associated with this. So it's still on the differential until effectively he's admitted and you're making sure he's not taking these. And you mentioned some of the other autoimmune conditions that we might not have evaluated for.

28:19Dr. Jordan Feigenbaum:Again, I noticed that you're still not saying exercise, although we don't have any other labs. It would be nice to have something like a creatine kinase to see like, oh, is that also elevated or like a myoglobin or lactate dehydrogenase, aldolase, something like that. You would expect those to also be elevated if this was exercise. But unfortunately, the lab, while running your antimitochondrial antibody, lost the sample and could not do that for you. So the initial workup for this patient included the viral markers and a liver ultrasound, all of which were negative. You've now ordered a third set of labs.

28:54Dr. Jordan Feigenbaum:But the patient says that he has some travel, so he can't get them done for a while, about two months after he returns. He says he travels a lot for work, which he generally enjoys, other than the fact he doesn't get to work out as much as he does when he's at home. So his new liver panel comes in and I'm going to send those to you now. So, yeah, the new liver panel came back or everything was normal, normal liver associated enzymes, AST and ALT, normal GGT, normal ALK-FOS, bilirubin, you name it. OK, so it's question time for you once again, Dr. Baraki, as well as the listeners at home. First question, one, how do you explain the resolved liver enzyme elevation?

29:32Dr. Jordan Feigenbaum:Two, what is your final diagnosis? And three, again, how are you explaining this to the patient? Yeah.

29:40Dr. Austin Baraki:So very good news for him in that his ALT is back down now into the 40s and his alkaline phosphatase is mildly improved from prior. Most of the rest of the labs are in a more or less kind of similar place, but generally a trend towards improvement, which is super reassuring. And so this leaves us with a few different possibilities. If there was, for example, an ongoing toxic exposure that may have been removed for long enough for things to get better, whether we ever identify it or not, that's one possibility. There are many other infections beyond just Hep A, Hep B, Hep C that can be, you know, injurious to the liver.

30:17Dr. Austin Baraki:And those viral infections can, for example, take a while and they can ultimately be cleared and lead to improvement. I really don't think that on the Barbell Medicine podcast, you're leading me down to an esoteric, you know, hepatotropic infection that we need to get to. But in real life, that would be on the list of possibilities of things that can do this. Autoimmunity, as we have talked about a couple times so far, is classically a kind of a pathologic phenomenon that can relapse and remit. And so people can have kind of more active forms of autoimmune disease followed by periods of kind of more relative quiescence where it calms back down over time.

30:55Dr. Austin Baraki:So that would also remain a possibility. But interestingly, I mean, you mentioned that he is, I think, generally quite healthy. We did not see evidence of severe, you know, fatty liver infiltration on his imaging. And so with this timeline, if he did not have substantial weight loss, that would no longer be a sufficient explanation for this kind of thing. Fatty liver disease, especially when you're manifesting elevations in liver enzymes, does not spontaneously remit absent substantial clinically significant weight loss, at least five plus percent, and gets better the more percent weight loss that somebody has.

31:30Dr. Austin Baraki:So if that has not changed, then now I've removed that from my list of possibilities. And you had mentioned, you know, that he is an avid exerciser, he traveled, maybe some changes in his exercise habits. And so that kind of brings us back to that original possibility, which we have never excluded from our list of considerations, but rather said it would be unwise to like commit to that as our diagnosis upfront, what in the face of those. And so a lot of times among athletes, people who are highly active, people who pursue consultations with us or ask us this question on the forum, they're like, I had these incidentally found elevated liver tests, but I train all the time and I know that it can cause it, what should I do?

32:07Dr. Austin Baraki:Sometimes it's just a matter of, yeah, you might not like it, but you might need to just suck it up and take a few days off or schedule your next lab draw, you know, at least a few days after your last training session. Maybe if you train during the week, you know, maybe reschedule your Monday session and get some labs done Tuesday morning to give yourself, I don't know, four days is maybe reasonable, but you know, people are different and you might still have some persistent elevations in that case. But you're right that along the way, you know, I would have already, I almost always do alongside these things, check some of those other tests, like an LDH, like a CK, some of those other things to try to differentiate where is the potential site of pathology here.

32:43Dr. Austin Baraki:And so, yeah, I'm back to some sort of exposure that is no longer present, an infection that was cleared that I might never actually be able to prove, autoimmunity that is, you know, in a remitting phase that is less likely at this point versus the removal of the exercise stimulus that may have contributed to some elevation in his liver enzymes. Which of those it is, I think would still require a little bit more longitudinal follow-up before you can put like a final stamp of there's absolutely nothing else here. This is just exercise. But that may be where we're headed at this point in the case.

33:19Dr. Austin Baraki:Hey, Sal.

33:20Dr. Jordan Feigenbaum:Hank, what's going on? We haven't worked a case in years. I just bought my car at Carvana and it was so easy, too easy. I think something's up. You tell me. They got thousands of options, found a great car at a great price, And it got delivered the next day. It sounds like Carvana just makes it easy to buy your car, Hank. Yeah, you're right. Case closed. Buy your car today on Carvana.

33:46Dr. Austin Baraki:Delivery fees may apply. With markets changing and living costs rising, finding a reliable place to grow your money matters now more than ever. In the Wealthfront Cash account, your uninvested cash can earn up to 3.95 % APY. That's a 0.65 % boost over an already high rate for three months just for being a new client. There are no monthly account fees or minimums, and you get free instant withdrawals to eligible accounts 24-7. So you always have access to your money when you need it. And when you're ready to invest, you can transfer your cash to one of Wealthfront's expert-built portfolios in just minutes.

34:19Dr. Austin Baraki:More than 1 million people already use Wealthfront to save and build wealth with confidence. Get started today at Wealthfront.com. 3.3 % base APY via Program Banks as of January 30th, 2026. It is representative variable, requires no minimum, and is earned on funds swept to Program Banks. Instant withdrawal subject to conditions boost up to$150 ,000. Cash account offered by Wealthfront Brokerage LLC member FINRA SIPC, not a bank. Investing involves risk, including possible loss of principal investment advisory services provided by Wealthfront Advisors LLC and SEC registered investment advisor.

34:48Dr. Jordan Feigenbaum:Yeah, it's a pretty interesting case. apparently for this particular individual before every lab draw that he remembers, he would go to the gym and work out. He's an AM exerciser. And so, yeah, the final diagnosis they arrived at was exercise induced elevations in his liver associated tests. Now you spelled this out quite nicely that with exercise, the reason why these liver associated enzymes go up is because there's some muscular damage. And subsequently, there's a release of these intracellular enzymes into the blood. And you pick that up on a blood test. Now, how that happens, strenuous exercise depletes ATP, that's energy, and damages some of the ion channels of the muscle cells themselves, which leads to an electrolyte imbalance.

35:37Dr. Jordan Feigenbaum:Effectively, the muscle cell now gets flooded with calcium and sodium. This causes the cell to swell. and together the cell swelling and the electrolytes now inside the cell break down the muscle cells membrane which is the sarcolemma that allows the intramuscular enzymes like ast alt creatine kinase etc to leak into the extracellular space and subsequently the bloodstream which brings me to point number one while alanine aminotransferase and aspartate aminotransferase these are also often called liver enzymes, that's kind of a misnomer. They should be more appropriately termed liver-associated enzymes because they're found in several tissues, particularly skeletal muscle.

36:19Dr. Jordan Feigenbaum:In this case, also the heart, kidneys, you know, ALT is less, you know, less expressed in the muscle, but it's there just at a smaller or lower concentration. So when a person engages in resistance training, especially resistance training that involves a lot of eccentric loading, where the muscle produces force as it gets longer, that's a downward phase of most exercises, the muscle can experience microtrauma, which again increases permeability, allowing enzymes like creatine kinase, AST, ALT to leak into the bloodstream. This is normal physiology, not necessarily a sign of liver dysfunction, which brings me to point number two.

36:56Dr. Jordan Feigenbaum:It's unavoidable. In a study of 15 healthy men who lifted weights for one hour at 70 % of their one rep max, 100 % of participants saw a bump in their liver-associated enzymes, the AST and ALT. The average is about three times normal for AST with a smaller bump for ALT. It seems to be more pronounced in people who are untrained or who are coming back to exercise rather than individuals who are chronic exercisers or lifelong exercisers. But lifelong trainees cannot really avoid this entirely either. It just seems to happen just at a lower level. We think the reason why it happens at a lower level or that there are smaller increases is due to a couple things.

37:39Dr. Jordan Feigenbaum:One, there's reduced muscle protein breakdown in trained individuals during a workout. And that seems to be an adaptation. Also, one of the mechanisms by which people actually grow new muscle. The muscle protein breakdown goes down enough so that the muscle protein synthesis, muscle growth actually outpaces that. So you get bigger muscles. the other thing is you get an increase in plasma volume from training a long time effectively if you sweat a bunch your body adapts more more fluid so there's like a little dilution of things in the blood including liver associated enzymes and there's also and you might find this interesting an increase in albumin production in lifelong exercisers and albumin binds to calcium i think it's like 40 of the body's calcium is in albumin so there's less of that calcium mediated breakdown of the sarcolemma that can happen because more albumin is being produced.

38:29Dr. Jordan Feigenbaum:So a little nerdery, as we are known for here. News to me. Yeah. The elevations tend to be higher in men compared to women. They generally have more muscle mass and a higher baseline level of these liver associated enzymes. There's also a strong genetic influence with some individuals being, quote, high responders to exercise, not in the terms of seeing gains necessarily. It's not necessarily like correlation where the higher your liver associated enzymes are, the more gains you have, but some people just genetically will have a more robust increase in their liver associated enzymes. We see that also with CK.

39:04Dr. Jordan Feigenbaum:There's like a condition called hyper CKemia where people just put out a ton of CK, creatine kinase. They don't have rhabdo, but just their genetic sort of lot that they've inherited. And other factors like exercising in hot or humid environments tend to produce higher levels of these liver associated enzymes, as does alcohol consumption. Point number three here, it takes a while to normalize. Based on available data, AST and ALT continue to rise 48 hours post-workout, and they may take up to four to five days to peak, and they typically don't normalize until 10 to 12 days after workout, provided a person is continuing to exercise.

39:44Dr. Jordan Feigenbaum:Part of this delay is structural. The muscle cells sarcolemma, its membrane doesn't degrade all at once. It's a gradual process, which makes some of the intramuscular, intracellular contents slowly leak out, not all at once. Also, ALT tends to peak later with some studies suggesting it takes as long as six to seven days to peak post workout. It could be influenced by the longer half-life of ALT compared to AST. But yeah, it's kind of up for debate right now. Point number four here is that it's mostly harmless, particularly from exercise because it's a transient benign phenomenon that represents skeletal muscle damage and repair rather than a condition that leads to long-term issues in the liver because these enzymes leak from a sort of micro tear in the skeletal muscle fibers rather than the liver itself the liver is usually doing fine and this is true even when an athlete or lifter appears to have sort of chronic elevation as in this case we've got like 12 years of data showing this like chronic elevation.

40:43Dr. Jordan Feigenbaum:And you're like, is this a smoldering sort of disease? Or is this person just always exercising before every lab draw? And this exact case report, the guy was referred to a gastroenterologist who basically said, hey, don't work out for like a week, come back in and then we'll test again. And then his labs normalized. But it is a normal, healthy physiological adaptation to regular training. So, you know, when explaining this to a patient probably would want to emphasize that so they're not afraid of some unnecessary anxiety around why are my labs elevated i'm otherwise healthy or is is this exercise harming

41:18Dr. Austin Baraki:my liver because depending on how you phrase this again if the focus you know understandably the diagnostic momentum here is oriented towards some sort of liver pathology but if you kind of depending on how you explain it it might convey the message implicitly that like oh you're harming your liver by exercising, which is not the case. Yeah.

41:36Dr. Jordan Feigenbaum:Yeah. It actually brings up an important point, you know, in a survey of physicians that were given a case where a young asymptomatic man had elevated liver associated enzymes, 56 % of those physicians failed to list exercise induced muscle damage in their differential and over 60 % listed primary liver disease as their diagnosis. So why do you think clinicians often overlook exercise history in the context of screening asymptomatic young adults?

42:03Dr. Austin Baraki:Yeah, I mean, I see this all the time, although it's less often in asymptomatic adults because it's more in the hospital ER setting where everybody is kind of trained to think in terms of worst case scenario types of thinking. I think it's a combination of things, probably under emphasis in training. Also, that it's just not something that people see very often. So if a traditional regular primary care doc is seeing, you know, a thousand patients with incidentally found elevated liver enzymes, the overwhelming majority of these are going to be related to fatty liver disease and alcohol, at least in most clinics in the United States, less and less likely related to maybe chronic hep C or some drug-induced issue or something else.

42:42Dr. Austin Baraki:The frequency with which they will be seeing pure exercise-induced elevations is super, super low. And as I said this whole time, that should not be your first assumption when you see this type of thing. Even if I saw somebody who told me, I'm a regular exerciser and I found elevated liver enzymes in them, my first thought is not, oh, this is probably just exercise, but what supplement are you taking? Because again, I need to be finding the things that are more dangerous, more life-threatening, more potential for morbidity in this patient, rather than assuming the least dangerous cause up front.

43:18Dr. Austin Baraki:Now, I might eventually get there, as of course we did here, but I would not feel comfortable making that assumption up front. It is totally fine to tell somebody or to inquire about their exercise habits and to try to repeat the tests, you know, absent exercise. But with that repeat test, I would probably still be sending a bunch of other stuff at that at that same time. So I think it's a combination of just like, how prevalent is this as a problem? How often are people seeing this in the regular practice? And then what's the potential danger or risk of thinking about this first, compared with thinking about actual dangerous things first, and then like ending up at this later on.

43:53Dr. Austin Baraki:Now, as to your point, many of them will never get to this point. I have had one of the more memorable cases I think I mentioned on this podcast before was a young patient I had who had severe rhabdomyolysis and his CK was greater than 100 ,000. So severe, severe rhabdo. His AST and ALT were somewhere between 3 ,000 and 4 ,000, which is our levels that we usually see with acute liver failure. So everybody was losing their minds. He had liver enzymes. They were calling for acute liver failure, even though his INR was completely normal and his, you know, mentation, he was feeling fine in that way.

44:29Dr. Austin Baraki:So he didn't actually, you know, meet diagnostic criteria for that kind of thing. But again, worst case scenario, if this guy's liver is shutting down for whatever reason, like that would be something that you could die from. And then when I saw the CK was greater than 100 ,000, I said, oh, this is way more likely to be muscle elevation. It's just so high because of the degree of severity of his rhabdo. And sure enough, that ended up being the case, but it was not necessarily safe to assume that up front. And I get called for admissions all the time on people with abnormal liver enzymes, and they haven't checked the CK.

44:59Dr. Austin Baraki:And then when I do check the CK, the person ends up having rhabdo. And then we do the exercise history and oh yeah, it all kind of fits or something like that. So really common. I think it's just a matter of prevalence and training and exposure. And then we're all trained to think in terms of worst case type stuff, dangerous stuff before we assume the more benign things. Yeah, that makes sense to me, especially considering

45:19Dr. Jordan Feigenbaum:you know, there's some gaps when a clinician is looking at a given set of labs, given, you know, history of present illness, given narrative, you know, there's just holes there. So I'm trying to create a scenario where you'd feel very confident that in saying, yeah, this is definitely exercise induced elevation of liver associated enzymes. And so I think about a patient comes in there again, they're asymptomatic, right? But they just have this lab abnormality, but it is accompanied by an elevated creatine kinase. It's elevated by lactate dehydrogenase. That's, that's up. They say they exercise all the time.

45:57Dr. Jordan Feigenbaum:They have, again, no, no symptoms. They got a normal clotting factor. Yeah. You know, I'm trying to trying to create this for you. Is there any scenario, you know, and it may be a normal GGT as well. So is there any scenario where you'd feel very confident like, yeah, this is exercise. We don't need further testing. Or is it more like, no, you came into the medical office and now my spidey senses are tingling?

46:23Dr. Austin Baraki:I don't think that there's one of these scenarios where I see that initial set of tests and I say, no, there's just no need for additional testing. I would probably recommend and feel best if there was some form of repeat testing regardless. it may be after a period of pausing exercise and it also depends on how much how confident i am in my history taking from this person how much i trust that they are not in fact using any sort of a supplement that may be contributing to it because i just see that so so often of supplement induced liver injury that i'm gonna even in an exerciser it's like it's probably more at least as common that somebody is using a supplement that's causing it as the exercise itself is causing it and i need to entertain both possibilities but just to see a one-time you know, upfront snapshot elevation of ALT into the nineties and be like, ah, nothing, nothing to repeat, nothing to worry about.

47:07Dr. Austin Baraki:I would not actually ever do that.

47:09Dr. Jordan Feigenbaum:Yeah. Uh, so that brings me to point number five, GGT, uh, is an enzyme that has been put forth as sort of this differentiator, um, in, in cases like this, where some have suggested that, look, if you have a person with an isolated elevated transaminitis, so just elevated AST and ALT, but everything else is fine, including their GGT that effectively you could say most likely this is due to exercise and the reason why is that GGT is not in the muscle it's absent there and it doesn't typically rise post workout therefore if a patient presents with highly elevated AST and ALT but a normal GGT then maybe you could just write this off as exercise induced muscle damage now to me that seems a bit aggressive not knowing anything else I need to have some other assurances like maybe a recent hepatitis serology set, for example, maybe an abdominal ultrasound.

48:04Dr. Jordan Feigenbaum:But this particular patient was interesting because his GGT was elevated. And so then you're like, that shouldn't happen. And things aren't so simple in medicine. Sometimes this does happen. This can be elevated post-workout. There's been some studies suggesting up to 10 % of individuals who have ran a half marathon that their GGT is elevated. Two potential mechanisms here. One is altered liver blood flow during strenuous exercise, diverting blood away from the internal organs and towards the skeletal muscles. So this can decrease again, the blood flow. And so you get some increase in permeability of the hepatocytes of the liver cells, which allows liver enzymes like GGT to leak into the bloodstream.

48:47Dr. Jordan Feigenbaum:There's also a thought that this is part of the repair process of muscular damage, which we discussed in relationship to glutathione and the damage to the muscle cells membrane, the sarcolemma. So GGT is thought to be involved in making like amino acids available to cells for tissue repair. So those are the two mechanisms there. But yeah, this patient had an elevated GGT.

49:08Dr. Austin Baraki:So like you couldn't even write that off. Yes, that is part of why, you know, my answer was no, there is no scenario where I would just say no further testing needed because testing, it's just never so simple. There are all tests are imperfect. And there can be failure to detect things that it should detect or over detection of things that shouldn't. And I think it's more people want this stuff to be simple and easy to interpret. And it is just fundamentally not. And once you have been doing this for long enough and you have looked at enough labs and interpreted them and correlated them to what's going on with the patient, you realize the flaws and the gaps that you have to kind of mentally account for so that you don't make mistakes in your thinking by being overconfident in your lab numbers.

49:50Yeah.

49:51Dr. Jordan Feigenbaum:And speaking of being overconfident in lab numbers, one thing that really bothered me about this case, the dude had an elevated ALKFOS like almost the entire time. And I'm like, I cannot square this with anything that I know at this particular time relating to exercise. So down the rabbit hole, I went. It turns out ALKFOS is routinely elevated post-exercise, particularly in load-bearing exercise because there's some additional bony turnovers at that time. It, on average, peaks about 20 minutes post-workout and takes close to an hour to return to normal. So if this guy was going in and working out hard in the morning, then going right to the lab.

50:35Dr. Jordan Feigenbaum:Yeah, that's funny. The timeline makes sense to me. But yeah, when I was looking at his labs, I'm like, look, again, if it was just AST and ALT and the traditional pattern, GGT was normal, no ALKFOS, no history of this stuff over, you know, 12 years. Sure. He could make a case that like, yeah, I would have picked up on exercise induced elevations earlier, but yeah, it kind of threw me off the scent.

50:55Dr. Austin Baraki:Yeah, that's interesting. I think, you know, I'll stick by my position that his ALKFOS elevation was really quite mild and actually wasn't the center of my concern. If it was substantially higher, then that would have definitely drawn my attention in a different direction. And just to like contrast it, for example, with a patient who I spoke to just within the past couple days, this was a woman who has, I would say, mildly elevated transaminases into their similar ranges to what we see here. However, her alkaline phosphatase is in the 400 to 500 range. So much, much, much higher, like five times, greater than five times, kind of the upper limit of normal.

51:34Dr. Austin Baraki:that is like where my attention locked in. I said, oh, I'm not nearly as concerned with the transaminases, but that elevation in alkaline phosphatase that has been persistent and chronic, and I'm actually quite confident that this patient has PBC, primary biliary cholangitis, has that condition that you actually mentioned that they tested for in this case as well. And so that's just a very different lab pattern that led me in a very different direction of how I was thinking about that patient? Yeah.

52:00Dr. Jordan Feigenbaum:So I think this case proves that a lab value without lifestyle context can be hard and potentially costly to interpret both ways. Either not enough workup could potentially put a patient on a road to unwanted disease and unwanted outcomes. And then over-interpretation, you know, if this patient had a liver biopsy, that would be a bad outcome as well. But ultimately, the leakage of these enzymes, these transaminases, and even GGT from exercised muscle cells is well documented. But there's a disconnect between exercise science and modern medicine. To start, you kind of alluded to this. There's probably a cognitive bias stemming from calling these liver function tests, suggesting that there's like a liver-only origin, which is not true.

52:45Dr. Jordan Feigenbaum:They are present in many cells, including the muscle, so not just the liver. Yet because of that naming convention, it's hard to look past the liver, even when the patient is perfectly healthy and asymptomatic. Next, physicians often don't ask about exercise. It's hard to come up with a solid number on this, but available data suggests that less than half of patients in the primary care setting have any documentation of their exercise habits in their chart. So if we're not asking about exercise, it's hard for that to arrive on the differential. So my thought is that as a result of being liver-focused and exercise agnostic, many clinicians see a slightly high ALT.

53:20Dr. Jordan Feigenbaum:They'll order an ultrasound, they run the hepatitis serology, and they repeat the panels all without ever asking about the patient's exercise habits. The costs of this can be immense, not only financially, but also in patient stress and anxiety. Austin, if you could wave a magic wand and change clinical practice overnight, how would you have doctors approach this issue the next time a lab result hits their inbox, if at all?

53:44Dr. Austin Baraki:Yeah, I think that I hear the point that you're making here, that there is a little bit more information to be gleaned that could impact the way that people go about things. I think that there is a greater potential for harm by missing genuine liver disease than there is by nudging people to more often discount abnormalities in liver chemistry tests as being attributable to exercise. Now, I think you and I both agree that if more clinicians took an exercise history and were willing and able to effectively counsel patients on exercise and recognize that in some situations, exercise may well impact the accuracy and reliability and validity of their tests, then it might nudge practice in a little bit of a direction to where, you know, there might be a little bit less of, if you wanted to call it, like diagnostic overuse in these edge situations.

54:37Dr. Austin Baraki:at the same time i think the overall population prevalence of abnormal liver chemistries related to fatty liver disease where people are actually not exercising when they should even if it was right before their labs it's like i would rather that um is is far far higher than i think the incidence of like uh let's call it diagnostic misadventures as a result of somebody exercising too close to their to their lab draw but you know taking a detailed comprehensive history and making sure that you're the data you're getting is accurate and interpretable is a fundamental principle in all sorts of ways, not different than if I get a lipid panel on somebody and the triglycerides are off the charts.

55:12Dr. Austin Baraki:My first question is, was this fasted or not? Because that is something that can impact triglyceride accuracy. You could make a similar case that if you see somebody whose liver associated chemistries like this are abnormal, a question that you might ask is whether there was active or vigorous exercise done shortly before the test, and that might impact your confidence in the results. It should not lead you to discount them or to not repeat them, but rather maybe to repeat them in a different way, similar to how I might repeat a lipid panel in a fasted state if I wanted, if I needed to get a more accurate level, fasting triglyceride level, which is not often the case anyway, but it's something that would come to mind.

55:50Dr. Austin Baraki:So those are kind of my thoughts.

55:51Dr. Jordan Feigenbaum:Yeah. What I'm hearing you say is that in a new undifferentiated patient, it would be very challenging to overlook elevation in transaminases and just chalk it up to exercise unless you had a ton more information. And even then, you'd be kind of stretching your clinical acumen and say, okay, I feel okay about this, but you wouldn't feel great.

56:13Dr. Austin Baraki:Yeah, exactly. I would probably be repeating them and I'd probably be bringing you back to grill you about what supplements you're taking again and make sure you're not drinking too much and not telling me.

56:21Dr. Jordan Feigenbaum:Yeah, I think the best case scenario is if you had more clinicians asking about exercise, it's highly likely they're more likely to counsel them on exercise to the extent that's beneficial. Yes. Yeah.

56:32Dr. Austin Baraki:That might, that might do more to fix more elevated liver enzymes that are actually from fatty liver disease that would respond to more vigorous exercise. Exactly. Yeah.

56:39Dr. Jordan Feigenbaum:Yeah. Yeah. That number needed to treat, I think is what 12 primary care physician needs to counsel 12 patients to get one person to take up and sustain exercise for a year. Pretty, pretty good numbers. Um, okay. Let's, let's turn this on its side for a second for listeners who may be dealing with a skeptical primary care physician, not Dr. Baraki, of course, uh, there There are a few strategies that I would like to put forth to help them avoid maybe unnecessary care and, you know, anxiety without a big time risk of missing a serious condition. So one, you could inform your physician, hey, look, I engage in heavy resistance training and endurance exercise, and I worked out shortly before my last blood draw.

57:19Dr. Jordan Feigenbaum:I understand that intense exercise causes muscle micro damage, which can leak enzymes like AST and ALT into the blood that can look like liver damage. can we you know follow up with some labs you know in a in a week or two after i uh take a break from exercise before any further imaging or specialist referrals that seem reasonable to you yeah seems

57:41Dr. Austin Baraki:reasonable and tacking on a ck uh would be also supportive in that context as well i think that's

57:46Dr. Jordan Feigenbaum:fair yeah for those who want to avoid taking a week off i can just imagine you being counseled to take a week off on the one hand you know you probably would do it just to avoid any you know further uh kerfuffle but but maybe you maybe you wouldn't maybe you'd push back look hey doc can we repeat the test can we also add a ck can we add a lactate dehydrogenase perhaps and if my ck is highly elevated alongside my ast and alt it should theoretically confirm that these enzymes are coming from my muscles rather than my liver would you be on board with that in isolation i suspect

58:18Dr. Austin Baraki:No, but yeah, saying confirm is a high degree of confidence there. And so I think this is just a case where talking about it in the abstract is a little more challenging than having a real patient scenario in front of me to work through and see my like level of comfort. Now, if I'm confident that this patient has good access to care and follow up and they're willing to, you know, we're willing and able to monitor things over time, then doing a repeat with a CK. and if it's all kind of correlated, because this is also important, is remember how I was talking about how labs can have a predominant abnormality.

58:52Dr. Austin Baraki:And so if the transaminases are much higher than the alkaline phosphatase, it's like a much more hepatocellular pattern. If the alkaline phosphatase and the bilirubin are much higher, it's a more cholestatic pattern. It could be mixed. They could be evenly elevated. So I'm imagining a scenario, for example, where somebody's transaminases are like 180, 200, something like that. but the CK is like just very mildly elevated above the lower limit or above the limit of normal. It's like, I still am reluctant to chalk it up to that because the degree of abnormality is disproportionate. So need to be kind of concordant in that way for me to even feel okay.

59:28Dr. Austin Baraki:And I might still wanna monitor it over time because what's the worst case scenario in something like that? If you are to just assume that it's exercise is instead you're missing some sort of smoldering long-term process. And then years later, the person ends up developing more advanced liver disease, potentially even cirrhosis, potentially even needing a liver transplant. Like this sounds kind of crazy or catastrophic, but this truly does happen. And so like the patient that I alluded to, who I think has PBC, she has had some degree of liver abnormality and like chronic symptoms like itching and fatigue for the better part of a decade.

1:00:03Dr. Austin Baraki:and a middle-aged to older woman with like chronic fatigue and itch for like a decade, I'm like, okay, this may well be PBC. And that is something that is well-recognized, but the typical diagnostic delay in that condition is very long. And I would prefer to not be a contributor to that degree of diagnostic delay by saying, ah, it's just your physical activity. So that's kind of my hesitation. It would need to be a compelling story, good follow-up, concordant results that are kind of like tracking together reliably over time. and again like you quoted kind of average stats for what happens to these labs after exercise the average time to increase to peak to come down there's still a lot of variation around that i think you and i have both had our labs drawn and we have not ourselves taken prolonged time away from exercise even when we've gotten labs done and our liver chemistries at least i know mine are not terribly elevated and so um they're actually weren't elevated at all the last time And so maybe there's some degree of adaptation.

1:01:01Dr. Austin Baraki:Maybe I, you know, had a lighter session on Friday. Maybe I had the weekend off and maybe I got done Monday morning and that was just long enough for stuff to clear. But that's been my own personal experience is that it's not even the case for everyone that this always happens. There's a lot of variation between people.

1:01:15Dr. Jordan Feigenbaum:Yeah. All right. And in the final scenario, this is for the minimalist or the person who wants to do the least. Yeah. I suspect you will balk at this idea. Hey, Doc, look, since I'm completely asymptomatic, I feel fine. The standard guidelines suggest that mild elevations, so less than three times the upper limit of normal, I can be safely monitored with expectant observation. I'd prefer to watch and wait with a retest in four to six weeks. I'll take a week off of the gym before I go back in the labs.

1:01:43Dr. Austin Baraki:Oh, I'm actually completely fine with that. Oh, wow. I'm surprised. Well, the reason is the timeline that you gave me. Four to six weeks is not a long time. If he said, I'd rather just watch and wait and recheck in like a year and a half, no, I don't feel as good about that. But again, this was actually part of my counseling to this hypothetical or this real patient that we walked through where I said, look, there's some elevation. There's something going on here. We will get to the bottom of it. But the good news is that it's not severe, life-threatening imminently. We have time to figure it out.

1:02:12Dr. Austin Baraki:So I was kind of allaying that concern. And that's also why, like, when he said, oh, I have travel and I'm going to recheck them when I get back, I'd be like, okay, you know, there's a non-zero risk there. but I'm actually quite comfortable with it just because the degree is not in a severe situation. Somebody has transaminases that are actively rising, 300, 400, 500, 600. I'm like, no, no, no, no, we need to do this now. But with this degree of elevation, that's not a big deal at all. That's totally fine.

1:02:39Dr. Jordan Feigenbaum:Before we close out, here are the five things I want you to take away from today's case. One, ALT and AST are liver-associated enzymes. They're not exclusively liver enzymes. They're found in the muscle and exercise releases them into your bloodstream. Two, resistance training can elevate them to well above the normal range, and that's completely normal physiology, especially if you're new to training. Three, these enzymes can stay elevated for up to 10 to 12 days after a hard workout, so timing matters for when you get your labs done. Four, your physician might not think to ask you about your exercise habits when they see these numbers, and so you may need to bring it up yourself.

1:03:17Dr. Jordan Feigenbaum:And five, if your doctor wants imaging or a specialist referral, it is completely reasonable to request a repeat test after a week off from training first. That's the move. Full episode is linked below. And if this helped you, please leave us a five star review. It's the single best thing you can do so that we can keep bringing you all the latest nuance and health and fitness. All right, Austin, any other tips for our would be patients who are currently listeners?

1:03:39Dr. Austin Baraki:Don't try to interpret your own labs. Get some expert consultation doing labs, interpreting labs is complex. It is challenging, even for experienced clinicians. I do a lot of these as part of our kind of barbell medicine consults here and there. I do it with patients and I'm happy to help people through that process myself. But yeah, don't try to do this on your own would be my main advice.

1:04:05Dr. Jordan Feigenbaum:Yeah, that's good advice. All right. So that is a wrap here on the barbell medicine mystery case. Hopefully you guys took home something useful. Before you guys go anywhere, please leave us a five-star rating and a review. It really helps drive traffic to our podcast. We can keep bringing you all the latest nuance in health and fitness. Special shout out to Dr. Austin Baraki for joining me on the podcast. I'm Dr. Jordan Feigenbaum. We'll catch you next week and every week right here on the Barbell Medicine Podcast.

1:04:38Dr. Austin Baraki:If you're a podcast host, listen up, this one's for you. My name is Allie Jackson. I'm the host of Finding Mr. Height, a dating and relationship podcast that I've been doing for four years now, sharing my positive and practical approach to dating that's built on my own life experience. And I wanted to share another experience that I've had, my secret behind monetizing my show. It's called Red Circle. And I was just telling my colleague about how much I love their platform. With Red Circle, not only am I getting a seamless hosting experience, but I also love the support I receive in ad sales. It's not just typical ad sales either.

1:05:07Dr. Austin Baraki:It's targeted opportunities based on my show and my life. And the platform is super simple. You just set your preferences and Red Circle matches you with sponsors that align with your show. You can vet every opportunity and their platform gives you great analytics. More recently too, my Red Circle team has brought me opportunities outside of my podcast on social media to really augment the podcast partnerships, bring them full circle. I just can't recommend them enough. If you want to give it a try, go to redcircle.com to get your free trial. That's redcircle.com for a free trial.

1:05:35Dr. Jordan Feigenbaum:You've probably noticed that we're doing more ad reads lately to keep the lights on and the microphones powered up. But if you want to skip all of this and get straight to the science, you should check out Barbell Medicine Plus. It's our premium subscription that lets you listen to the show entirely ad free. Beyond just skipping the ads, you also get early access to all of our new episodes and product launches, plus exclusive content that does not go out on the main feed. And on top of all that, you get exclusive discounts like 10 % off all of our programs, 15 % off consultations and 25 % off courses and seminars.

1:06:04Dr. Jordan Feigenbaum:all while supporting the work we do here at Barbell Medicine. My favorite part is the direct line, our monthly ask us anything where you can ask Austin and I your specific questions. Trust me, it's a lot more efficient than trying to hunt us down in person or by sliding into our DMs. And it costs about the same as a cup of coffee each month. And look, I know what a good bag of beans cost these days, but really we're talking about a very reasonable investment here. Plus the first month is only a dollar. So there's basically zero risk in trying it out. To join, head over to barbellmedicine.com slash plus and sign up today.

1:06:34Dr. Jordan Feigenbaum:That's barbellmedicine.com slash plus. We really appreciate the support. Now let's get back to the show.