Should I agree to further testing?

Hi Doc -

I'm a 31 year old male with crohn's disease and recent history (past 3 to 4 months) of consistent mild elevation in liver enzymes AST and ALT (slight elevation of AST or normal, but ALT around 100).  My blood tests so far for Hep or other diseases (first round I take it) have been negative. I have an appt in a few weeks with the hepatoligist, but I want to be prepared with answer should he recommend a liver biopsy or any further imaging studies.

Some relevant background: I have had 2 relevant scans of the abdomen/pelvis for crohn's workup.  The first was a CT two years ago ago, taken because I came down with unexplained high fever (104) for about a week.  WBC was normal, but AST/ALT/AP all elevated in the 200 range. Fever went away, and this was never explained (it did start after I ate cooked muscles, and although I have had my Hep vacines, I wonder if this was the cause). CT showed no absesses, usual inflammation in small intestine, but also showed "mild hepatosplenamaglia".

The second scan I have had for crohn's was an MRI abdomen/peliv about six months ago. Liver was unremarkeable.

Would this background suggest a liver biopsy or further imaging studies? Is the MRI for crohn's that images the liver as part of it as effective as a liver-specific MRI or perhaps ultrasound? I note that there is correlation between autoimmine diseases and possibly primary bilary scheloris with diseases such as crohn's.  Should those be tested further by biopsy? Or does the normal AP contra-indicate bilary disease?

I'm currently on Humira but the elevated liver enzymes started before the humira, and I understand that humira, unlike other crohn's treatments, is not known to cause liver damage. (I may be mistaken.)  

Thanks! I like to be "in the know," particulary before I get a large needle stuck into my chest.

[Kevin Pho, MD]

To answer your questions:

1) Normally a liver biopsy is recommended when the enzymes are 3 times the upper limit of normal.  That number is normally slightly higher than 100.  So persistent elevations in the 200 range would make a biopsy reasonable.  

2) I agree with the CT scan and MRI.  The MRI is a very sensitive test, and if negative, I probably wouldn't recommend further imaging.

3) A normal AP would argue against biliary disease, but this isn't a 100 percent accurate indicator.  

You may want to obtain another GI opinion if there continue to be questions about the liver biopsy.

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 Pho, M.D.
www.kevinmd.com
www.twitter.com/kevinmd