What are the causes of elevated transaminase levels in individuals with positive hepatitis B surface antigen, e antigen, and core antibody (commonly known as "three positives")?

Elevated transaminase levels in individuals with "big three positive" (indicating active hepatitis B) may result from excessive alcohol consumption, chronic sleep deprivation, or intense physical activity prior to testing. This often leads to transient increases in transaminase, which usually improve with dietary adjustments and adequate rest. However, persistently elevated transaminase levels could also be due to underlying liver damage caused by conditions such as hepatitis B, alcoholic liver disease, drug-induced liver injury, or fatty liver disease, as well as biliary tract disorders including gallstones, biliary infection, or cholangitis.