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Extremely high AST/ALT/GGT. Liver? Gallstones? ...?
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Extremely high AST/ALT/GGT. Liver? Gallstones? ...?

My brother is a 29 year old (male), does not drink alchohol & has never smoked. He has very high levels of AST-252, ALT-578, GGT-216 way out of range. Values summarized at the bottom.
He's been very stressed for the last 2 years. (job related)

Jan/04: Chest pain once (2 hours long) no vomit.
Feb/04: Pain 2 times, no vomitting
Mar/04: Pain 4 times + vomiting, OK after vomit
Apr/04: Pain 8 times + vomiting, OK after vomit
May/04: Pain ~every day with vomiting and the pain
remains for 5-10 hours after vomiting. Pyloris ???

06/04/04: Hepatitis A/B/C negative. Ultrasound and
X-rays found sand in bile duct. Ductus choledochus very wide - 17mm, bile ducts widened, intrahepatic ducts very wide, normal pancreatic duct, no gallbladder concrements. Very high AST-119, ALT-400, GGT-720, no bone problems. Blood pressure - high.

06/08/04-06/17/04 Hospital: ERCP :
Papilla incision 12 mm - endoscopic papilliary sphincterotomy. Pain and vomiting stopped. Black substance leaked out. Ductus choledochus still wide -11mm. Antibiotic treatment was done. Pancreas not affected.
At release time 06/17 AST/ALT/GGT were normal. 30 days later they were times out of range again. He felt great, though.

08/04/04-08/23/04: Hospital 2nd time:  
ERCP again - cutting 5mm more into the papilla (17mm total);
"gallbladder mud" got released again, but a pancreatic infection
followed. At release time 08/23 AST/ALT/GGT were fine again.
All nutrition was through IV for weeks. Release Exams:
Liver: homogenous structure & normal size.
Gallbladder: no concrements, microlithiasis and cholesterosis.
Ductus choledochus: 10mm in its distal section
Pancreas: normal morphology and structure
Kidneys - OK; Extrahepatic bile ducts NOT wide.
Persistant extrahepatic cholestasis with ultrasound data for weak/low extrahepatic stop with widened ductus choledochus. AST/ALT/GGT normal.
A week later (09/01): values were very high again.

1. Is it the liver or gallbladder or ...?
2. How dangerous is his liver situation?
3. What is the risk for liver cirrhosis?
4. Can removing the gallbladder be a solution for him?
5. What should he eat/not eat?
6. What could be the root cause for all this?
              _______________________H1st______________H2nd___
*Dates 2004  |03/22|05/25|05/27|06/04|06/17|07/15|07/21|09/01|
AST ......:  |___34|__316|__342|__119|___42|__296|__251|__252|
ALT ......:  |___12|__566|__702|__400|___62|__562|__422|__578|
ALP.......:  |_____|_____|_____|__140|__155|___73|__248|__106|
GGT ......:  |_____|__587|_____|__720|__151|__184|__199|__216|
TBIL .....:  |_15.9|___77|_47.7|___30|_13.7|_15.7|_____|_13.1|
DBIL .....:  |_____|_____|_____|_____|__4.2|_____|_____|__1.9|
hmglb/Hb .:  |__166|_____|_____|__157|__138|__158|_____|__155|
eritr/ERYS:  |__5.4|_____|_____|__5.4|__4.9|__5.6|_____|__5.5|
LEUC .....:  |__9.8|_____|_____|__9.3|__4.3|__6.2|_____|__6.8|
CYE ......:  |____5|_____|_____|___20|_____|____4|_____|____7|

Thank you!
PA
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To answer your questions:
1) It seems like the problem is can be traced back to the sphincter, since the enzymes normalized each time after the sphincterotomy.  Success rates for this surgery is about 50 to 60 percent.

2) Certainly if the liver enzymes continually stay elevated (i.e. without treatment), there is concern for more permanent liver damage.

3) Cirrhosis is demonstrated via liver biopsy.  If the insult to the liver (i.e. the sphincter problem) goes unresolved, certainly the chances of progression to cirrhosis would be increased.  

4) I'm not familiar with the case, so I cannot comment if removing the gallbladder would help.  It seems the problem is with the sphincter (since the liver enzymes normalizes after the sphincterotomy), so it may not be helpful to remove the gallbladder.

5) You may want to discuss whether a low fat meal would help, which may decrease the amount of gallbladder contractions.

6) The cause of sphincter problems are not well understood.  It could be an anatomic abnormality (in the case of strictures), or local hormonal or neurologic disturbances can lead to motility issues causing the problems.  

Followup with your personal physician is essential.

This answer is not intended as and does not substitute for medical advice - the information presented is for patient education only. Please see your personal physician for further evaluation of your individual case.

Kevin, M.D.
Medical Weblog:
kevinmd_b
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