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Is Cirrhosis possible with negative Liver biopsy?
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Is Cirrhosis possible with negative Liver biopsy?

PT: 41 yo male, 10 yr HX heavy Etoh use (interdispersed periods of days, a week, a month or two with no Etoh, during those 10 yrs).

SX: fatigue, malaise, severe leg weakness and pain - even walking very short distances, chronic low grade fever in evenings (about 99.6), anorexia and early saiety, itching, maybe mild ankle edema (internist wasn't concerned), yellow discoloration on tongue.

Most Concerning, Perhaps:  Facial flushing (telangiectasia?), more acutely than chronic, started developing on cheeks bilaterally and spread to a permanent redness over face and mottled on neck.   (Dermatologist months later said this was poikiloderma de Cavette due to sun/climate, but it seemed to develop rapidly with the other symptoms - NOT over long period of time.)

Long HX varicose veins (with family HX).  Abd obesity (long-term since adolescence).  Fatty breasts, but bilateral with no tenderness (long-term since adolescense).

Labs: mild transient elevations of ALT and AST (50's, but ALT > AST).  Total Bili, Albumin, Globulin, Alk Phos, Ca+, LDH, (Chem 20 essentially), CBC within normal limits.

No palpable liver/spleen by internist and Gastroenterologists on exam.

CT Scan: No Abnormalities.

Upper GI scope: Mild gastritis (resolved with Reglan).

The SX above resolved after a few weeks with no booze, except for the facial redness which never went away.

About a month later,
Liver Biopsy Showed:

"Mild fatty liver," "Mild non-specific reactive hepatitis,"
"NO fibrosis."  No iron accumulation seen.  Also Negative for a few other pathological changes they look for on a liver biopsy, that the Pathologist commented on as negative in the full report.

(Sorry, don't remember all the specific terms, just know that the liver biopsy showed Nothing but mild fatty liver and mild non-specific reactive hepatitis, and said "no fibrosis present.")

So, the concerns are:

Could the on-going (now "chronic") facial erythema be due to a history of long-term alcohol abuse, without the alcohol having caused significant liver damage?

COULD there STILL be cirrhosis, even if an abdominal CT was perfectly normal and the Liver Biopsy only showed mild fatty liver and mild non-specific reactive hepatitis with NO fibrosis?

Thanks!

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The facial erythema can be due to alcohol.  You can also consider a dermatological condition.  A skin biopsy would be the most definitive test for this.

However, if that route is non-revealing, you can consider an allergic reaction - which can be evaluated by an allergist.  

A negative liver biopsy will make cirrhosis very unlikely.  I would look elsewhere for a cause of the liver complaints.

Regarding the leg weakness and pain, you can consider evaluating for peripheral vascular disease, or obtaining a neurology evaluation for a closer look at the cause.

These options can be discussed with your personal physician.

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.
kevinmd_
5 Comments
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Avatar_n_tn
Wow! Your telling my story. I drank for 10 hard years straight. Ended up with the syndrome of severe alcohlic hepatitis but with only transient elevations in liver enzymes which normalized long before the rest of the symptoms. All the symptoms you mentioned applied to me as well. I lost 28 pounds in 5 weeks. I managed to get a liver biopsy 5 month's later which stated trivial fatty infiltration, no fibrosis, and non-specific mild inflammation. However, 13 month's later I am still reeling from the effects, still upset stomach, red hands etc.

I also had transient telangecstasia right under my eyes which was pronounced most when I was most sick ,but my liver enzymes were normal at the time (At that point, I had not been drinking for 2 weeks).

Alcoholic Hepatitis can leave spotty cirrhosis from what I've heard which may not be found on biopsy.

A couple of things you might keep an eye out for include Red Hands which are a sign of chronicity and dilation of blood vessels in your hands which can be the effect of generalized vasoldilation resulting from generalized vasodilation and blood flow changes in the liver. I would be very curious to know the doctors take on this.

In short, I think liver biopsy's are highly likely to miss liver disease more often than not. I don't beleive that Cirrhosis is necessarily a widespead/liverwide pathology. SOme liver tissue can be unaffected, other tissue can be dramatically effected. I think one of the most telling things is the mild reactive hepatitis in your biopsy. In the abscense of any medications and active alcohol use, that has to be caused by something. possibly a metabolic change in collagen deposition or immune function. I don't mean to put a downer on you. The clear liver biopsy gives room for feeling positive about the future of your health, but I would say you are in the cusp on mending or making it worse. Take care of yourself, stay off the sauce, pray and be thankful.
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Avatar_n_tn
How much drinking do you mean by heavy drinking, if you don't mind me asking?  Did you stop because of health anxieties?
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Avatar_n_tn
cantlivenotknowing - - -


[quote]   However, 13 month's later I am still reeling from the effects, still upset stomach, red hands etc.   [/quote]


13 months?  OMG.

Actually, mine happened over a year ago.  My symptoms resolved in a couple of weeks with no booze.

Two Gastroenterologists were adamant that there was no cirrhosis.  The first one, who did the CT Scan (normal) told me everything I had sounded Rheumatoid, and "go see a Rheumatologist."

I got a second opinion from another GI Doc in about a few weeks.  I practically had to "plead" with him for a liver biopsy.  He dismissed the results  - - -

I followed-up for the results with his P.A. who assured me their was no cirrhosis.  Said fatty liver was common with any alcohol use, plus I was very overweight, and that that resolves on its own.  Said the "few lymphocytes" noted on the Pathology report - i.e. "mild non-specific reactive hepatitis" was probably lymphocytes following in behind the inflammation of fatty liver.  Sent me along my way.

I looked for "non-specific reactive hepatitis" on the internet and found that it was basically regarded as benign and could have been from any number of things, i.e. a viral infection.

I stayed away from booze for nearly a year, no problems, bought a bowflex - muscle wasting definately not a problem, no problems bulking up the upper body.  Thought everything was great.

Problem is :( I guess I "rested on my laurels" and decided, "What the hell, a little moderation can't hurt me."  Then partied for about 7 weeks.  Not everyday, usually 2 after work to "wind down."  A couple of times getting wasted, kind of on purpose, though.

Anyway, I suddenly wised-up and thought, "This could be very dangerous."  I started having mild soreness in the top-upper legs and thought, "I ain't goin' down that road again!"  

Decided to stay away from it now.  With a "no fibrosis" biopsy way back when, I thought, you COULDN'T scar your (apparantly) "un-damaged" liver with only 7 weeks of partyin' up.  But, no . . . .  Decided that was NOT a good course of action to pursue.

Anyway, I would have the red palms periodically, but all cleared up that first time after only a few weeks booze-less.  They still sometimes "flush" when I lower my hands below my waist, then it goes away when raised back up to chest level.  I had an M.D. look at me like I was crazy when I freaked about that.  He said that is natural in fair skinned people as blood rushes downward, then back up again.  Actually, he did demonstrate the same thing on himself, just to show me.  Got to admit, he was right about that.

My GI tract is fine (appetite, stomach, etc.) as long as I stay away from booze.  Etoh irritates the gut anyway.

I'm curious about "white fingernails?"  Mine go from pink to whitish to pink . . . like changing underware.  I think it's been that way as long as I remember though(?)

I also remember in 8'th grade, a resident MD commenting on my red, mottled palms way back then (certainly no exposure to Etoh at that age).  I also think my anxiety level does "change the blood flow" (as I read somewhere else).

I read that facial redness can happen with any heavy Etoh use and be permanent, without liver involvement, as Etoh by itself damages the small blood vessels.

Anyway, thanks for your reply.  I was just curious to know if you had any experiences like what I described above?

I decided to post the original question about "false negatives" to the M.D. here, because I kind of freaked myself out, finally realizing that NOT staying away from booze is NOT a good thing.

Everything I have been able to find sounds like Liver Biopsy is the "Definitive Gold Standard" for diagnosis.  A couple of Gastroenterologists practically thought I was "crazy" for being worried about it in the first place, even when they knew about the Etoh history  -  and after seeing my CT scan and Liver Biopsy results.

So, thought another opinion on the "definitives" of biopsy might not be a bad question to post.
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Avatar_m_tn
Red, have you been screened for hep c? Have you had a blood test to specifically check to make sure you don't have it? About 40% of people whe contract it dont have a past IV drug history, you can pick it up in clinical settings although docs will tell you that isn't so, it sure is. Millions of people have it and have NO idea. It is a very sneaky disease and can only be detected through a blood test. I'd make sure to check for it.
I'd also go the no alcohol route and make some dramatic nutritional changes and make sure you get regular exercise,you might feel a lot better.
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Avatar_n_tn
Kalio1

Thanks for the input.

Oh yeh, I've had a complete Hep panel done.  No Hep-C, no Hep-B (and no Hep-A  -  that's the "acute" one from contaminated food).

I thank the Doctor for his reply and suggestions.  Put my mind at ease.  Symptoms already going away after a couple of days "booze-less."  Truthfully, I "know better."  Got to start taking care of myself - back on low-carb to get rid of the gut, back on the Bowflex, NO BOOZE!, get out and catch some fish ;), etc . . .  Just "freak-out" sometimes about health issues, and it made me feel better to post original questions for Kevin-MD.
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