slightly elevated alt

[boudyz]

I am a 51 year old female, 5'5", weighing 200 lbs. When I was 36 years old I was turned down for life insurance due to an elevated GTT. I have had my liver enzymes checked over the years and there are always one or two that are slightly elevated. For the past 6 years my alt & ast are always slightly more elevated than the previous years but never enough that my internists are particularly concerned. I used to be a dialysis nurse and I know I have been exposed to hepatitis. Plus I have travelled to several 3rd world countries. I have had hepatitis screens every several years and they are always negative. I have been worked up for Wilson's disease, which was negative. This past month my ALT was 87, 8 months ago it was 80. My AST this past month was 45, 8 months ago it was 37. If I understand correctly, the 2:1 ratio should be reverse with liver disease.  I have about one drink per week, I do not take medications other than Allegra, I am not hypertensive, hypothyroid, etc. I have gained weight gradually over the years but I was thin when my enzymes started rising. I had a screening in the past for an "enzyme deficiency"-test unknown, but it was negative. Several ultrasounds of the abd have been done and they are negative. The latest one, 8 months ago, showed a fatty liver. I have always been very healthy, although I have muscle aches, particularly in my hands and legs, everyday and have had for years. My allergist tells me that muscle pains could cause the elevated enzymes and that I need to go to a gastro-enterologist for a more complete work up. I have had several interns over the years and none have been concerned. One felt I may have Gilbert's Disease. Should I go see a specialist? Could destruction of muscle cells be the cause of my elevated enzymes? I have also thought of paying myself for further testing, particularly a CAT scan of the abd.
Thanks

[browncow116]

A related discussion, Liver function results was started.

[Kevin Pho, MD]

Erin, PA has kindly answered your question in her comments below and I agree with her assessment.

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.

Thanks,
Kevin, M.D.

[GI.PA]

First..lets list what has been ruled out thus far:
thyroid
viral hepatis
wilson's disease
"enzyme deficientcy"..I am not sure perhap alpha-1 antitripsin..but no mater

Your ALT has been in the twice normal range, AST lower (suggestive of low grade chronic inflammation, not consistant with alcohol use).

Your ultrasound repeatedly shows fatty infiltration but no other structural abnormalities.

Some thoughts that should be persued:
1.  autoimmune hepatitis (the test ordered is an ANA and if positve a panel of autoimmune markers can be obtained.  This diagnosis is confirmed with liver biopsy).
2.  Celiac Sprue (this is a gluten allergy and even without typical GI symtoms can elevate liver enzymes.  There is a panel of blood tests that can be ordered and if positive, the diagnosis is confirmed with small bowel biopsy).
3.  You have been screened for viral hepatitis (AB and C, I assume).  Since you have a significant risk factor (blood exposure through work and travel to possible hepatitis), further testing to be sure you dont have Hep C can be persued (the test is a Hep C PCR).  On occation, the antibody screening test can be falsly negative and you actually have the virus, therefor the need for additional testing with your history.
4.  Thyroid, you state is has been tested in the past, but if not in the past six months, a repeat screen is indicated.

Whew...with that said, if the lab work up is negative, one must assume that this is fatty infiltration of the liver (non-alcoholic steatohepatitis), for treatable and detectable other types of liver disease have been looked for.  If desired, the diagnosis can be confirmed by liver biopsy.

All in all, with your long history of elevations and the fact that the numbers are twice normal a one time formal GI work-up would be a good idea (to both test the above and any other ideas based on your complete history).

Fatty liver really isnt treatable.  Work is ongoing with supplement (such as Vit E) or medications such as Actigall but the mainstay is slow, steady loss of excess weight and good liver common sense.  This is thought to fall under the umbrella of a pre-glucose intolerance or early diabetes pathway of cause so careful screening for diabetes is indicated.  Tight control of cholesterol and blood sugar may be helpful in reducing further fat deposit in the liver (controversial).  And yes...this can happen even to skinny people, so the fact that you were of normal weight when the numbers were noted abnormal does not go against a fatty liver diagnosis.

Long term, fatty liver is usually a benign process.  In fact, until not to long ago, it was thought to never progress to further liver damage.  Now we know that a small percentage (perhaps 5%) can have significant liver problems (even cirrhosis or advanced liver failure) due to fatty liver damage over decades.  

Hope this helps.

Erin
Gastroenterology Physician Assistant
GI.PA

[boudyz]

Great! This is more information that I have been given in the past 15 years. I do wonder about the Celiac intolerance, there have been times that I have questioned if I have irritable bowel syndrome. I will print out this list and take it to a GI specialist. Thanks again.