Autoimmune Hepatitis and AntiSmooth Muscle Antibody

Hello all...i'm a 24 year old male (skinny/normal lipids) who has fluctuating ALT since Nov. 2003, In late August i started taking Restoril for sleep and then had a blood test 10 days later which showed an ALT of 58 and everything else normal. then i started taking toprol xl 12.5 mgs with the restoril at that time..on Nov. 28, 2003 the ALT was 101 and AST 61 which drew the doctors attention...since then i've monitored it regularly and it has gone up to the max of ALT 132 on April 1 and the AST has stayed around the 17-40 range..the ALT is usually around 83-92 range, but has also gone down to as low as 41 on one occasion on May 10. All other enzymes are normal.  i've had 2 normal ultrasounds, a normal mri and mrcp of liver, and normal hep a, b, c, normal for hemochromatosis, wilson's, normal gamma globulin and normal serum electrophoresis, normal for celic sprue, negative ANA, etc..THE ONLY positive thing that has showed up has been a slightly positive Anti Smooth Muscle Antibody..In December it was 1:40, and just last week in June it went up slightly to 1:80. My ALT was at 88 and my AST was 37 at that same time last week.
Does anyone think this sounds like Autoimmune Hepatitis? the hepatologist i see set up a Liver Biopsy for July 8. But he said usually people who have AIH have higher ASMA than i did.

Also, is the Liver Biopsy difficult? He said he's done over 3,000 in his life, but he uses x-mark the spot w/ an ultrasound. However, i was confused whether i should go with this route or go w/ the Intervential Radiologists who use the guided ultrasound the entire time?

And finally, what else could this be?  i've been tested for everything they can test for and only thing that shows up is a high ALT that fluctuates from high normal to around 100 and the slightly positive ASMA..what else could this be?  i know the biopsy will show what it is, but any ideas as to what it might be?

I've also been heat intolerant lately and i've had shortness of breath..i've had my heart checked out with echo and stress test, chest xray, thyroid checked, anemia, and everything has been normal.  i'm not having fluid retention at all either...can shortness of breath and heat intolerance be caused by a the liver and the high ALT?  

thanks for all your suggestions, ideas, help, etc. Best of health to everyone.

[Kevin Pho, MD]

To answer your questions:
1) AIH is possible with the elevated ASMA readings.  The liver biopsy would be a more definitive evaluation.  Anything else would be speculative.

2) A liver biopsy is a fairly routine procedure, lasting about 20 minutes.  As with any procedures, bleeding and infection can be complications.  More information on the procedure can be found here:
http://www.gicare.com/pated/epdlv27.htm

Gastroenterologists should be able to do the procedure proficiently.

3) You have had a pretty comprehensive evaluation that would rule out most of the other major causes.  With an ALT that high, not only would the liver biopsy evaluate for AIH, it can evaluate for other, less common, causes as well.  Shortness of breath can be caused by congestive heart failure, leading to liver failure.  Even with a normal echo, a B-naturetic peptide (a blood test to evaluate for heart failure) can be obtained to see if this is the case.

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

[dartmouth03]

i had room for another question..

do broken blood vessels/capillaries on the cuticles of your fingers on your hand have anything to do w/ liver disease?

thanks