Slightly higs ALT levels

I will try to make this short yet detailed.
I am a 40 Year old male 6' 210 pounds, non drinker (maybe 1 whine cooler per year) non smoker.
In June of 2002 I had a bout of Diarrhea that lasted for 3 days.  Not being of the thinking to overreact after 3 days I decided to
take some loperamide and the diarrhea ceased.  The following weeks were followed with intense sharp pains in the descending
colon area followed by diarrhea.  The occurrence of the pain and diarrhea were at least 3 times a week and were completely
debilitating.  After suffering through this for several months and loosing over 20 pounds, I made an appointment with a
Gastro-ent.  After examination he decided to do a colonoscopy to take a closer look of the colon.  The results were very
good.  He explained that the colon was free of any polyps or ANY abnormalities.  A biopsy was taken just to be sure.  All
negative was the result.  He prescribed at this time Robinul Forte 2 mg 1x a day just before the evening meal.  This appeared to
do the trick and I have had no other significant problems.  Eliminated several items from my diet that MAY have caused the
problem (Dairy, tomatoes, lettuce, most carbs)  During this time, under the care of my family physician, a blood test was
conducted to investigate a persistent back pain.  (Turned out to be 3 herineated discs) ( treatment was an epidural, and PT both
were very effective)  The blood test yielded a SLIGHTLY HIGH ALT level (reference range 2-60, mine was a 78)  Several
other tests were conducted over the following months which included, all Hepatitis variants, arthritis panels, AMA, FE, TIBC,
Ferritin, Copper, Ceruloplasmin, ultrasound and 4 other full liver panels including ALT.  Results ALT still stays around the 78
mark but never going over 80 but still sightless high.  Ferritin VERY slightly high, (like only one or 2 number over normal), Slight
inflammation shown by ultrasound.  My Gastro suggested it might be Fatty Liver, or too much iron but really had no idea.  He
suggested a biopsy but offered no idea as to what he was looking for, or had no idea of future treatments.  This left me uneasy.  
Several educated sources have suggested to me that a biopsy is neither easy for the patient or recommended in this case.  I
mentioned this to him and he became indignant and said that it might be Cancer and this was the only way to find out.  This left
me even less impressed with his recommendation and demeanor, I felt like he was looking for some extra money.  Having said
this I welcome your thoughts and recommendations.  Some thoughts come to mind, What if I am a person that normally runs a
78 ALT level and have done so for years?  What is the treatment for Fatty Liver?  I already walk 1.5 miles 3x a week with a
heart rate of 140 for 22 min. AND eat a low fat diet.  He seemed to indicate no suggestions for any treatment if it is this or that.  
In fact said that there was really no good treatment to date.  He did suggest one more blood test one that checked the ability for
my liver to process sugars (I forget the name of the test).  I have no family history for anything like this.
Suggestions?

[Kevin Pho, MD]

Hello - thanks for asking your question.

It seems you have had a comprehensive workup for your elevated liver enzymes.  Hepatitis variants, arthritis panels, AMA, Fe, TIBC, Ferritin, Copper, Ceruloplasmin, Ultrasound were all performed.  Ferritin was slightly high and ultrasound showed possible fatty liver.  

With a negative workup above, most of the obvious diseases would be ruled out (i.e. hepatitis, Wilson's disease, hemochromatosis etc.).  

Studies show that observation is an acceptable strategy for those who's liver enzymes are less than two-fold elevated and are asymptomatic with negative viral, metabolic, and autoimmune markers.  

Biopsy is recommended when the liver tests (ALT or AST) increase to more than twofold elevated.  

These are not hard and fast rules - your gastroenterologist may err on the cautious side, thus the recommendation for the biopsy.  

As for treating fatty liver - it depends on the cause (which may require a liver biopsy).  Alcohol is a common cause - treatment would be abstinence of alcohol.  NASH (non-alcoholic steatohepatitis) is another cause of fatty liver.  It is associated with high cholesterol, diabetes and obesity.  There are no proven treatments - weight loss and control of diabetes and obesity may help.

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.

[ConcernedGB]

Hello-
Sometimes biopsies are taken to test liver tissue for iron content in diagnosing hemochromatosis (i.e., a genetic, but manageable condition of the body's overabsorption of iron).  Don't worry about cancer.  Just do it and be glad you did!  Good luck!

[roxnsox]

Go to the American Liver Foundation website and read about Fatty Liver and Non-Alcoholic Steatohepatitis(NASH).  If you have only slightly elevated liver enzymes that means you have a little inflamation (inflammation) in your liver.  A small amount of inflamation (inflammation) could be caused by something as simple as Tylenol.  I wouldn't worry about a biopsy unless you have other symptoms of liver disease like fatigue or dull pain in your right side.

[KKIRCHNER]

Follow up if I may:
Your answers and time are appreciated.  You will note that from my first post I made sure to say that I am not a drinker and
have never been one.  I have MAYBE 1 glass of wine per year.  That's it.  So Fatty liver from Alcohol is remote at best.  
NASH is more probable but How? Why? or better yet how to treat.  My Gastro said low fat and exercise which I am doing.
So why recommend a more invasive procedure?  Over all I have had the ALT levels checked 5 times over the past months and
they are consistent.  A nurse suggested that I monitor this level with a test every 6 months just to keep an eye on it.  What may
the future hold for this?  Am I looking for the condition to worsen?
You suggest other factors like cholesterol, obesity, and diabetes.  My cholesterol level, when testes was only slightly elevated, 230, but has not been tested as of late.  I am far from obese at 6' 210.  Good bit of muscle because of my activity.  And
diabetes is ruled out in at least the case of no medical history of it in my family, ever.  Not mentioned in the first post but brought up here we have also ruled out trauma to the liver from injury.

concernedGB - there is only a slight increase in the Ferritin so that rules out hemochromatosis.

roxnsox - We have ruled out any other medications.  This was easy because I take nothing other than the Robinul.  However I was taking 1600 mg per day of Ibuprofen for a week during the fall of last year.  It should not effect my Liver at this point should it?  Fatigue?  Aren't we all tired?  Problem is how do wee tell if we are fatigued to an unusual level. I sleep 6-7
hours a night and keep going without any problem?

[kevinmd]

Hello,
Short of a liver biopsy, there is no sure way to say what you have.  You may or may not have NASH - I cannot say for sure without examining you.  However, my suspicion is low considering you do not have diabetes and are not obese.  

You have already had many of the tests to rule out serious diseases (hepatitis, hemochromatosis, Wilson's disease, autoimmune disease etc.).  

Your liver enzymes are less than twofold elevated.  Studies have shown that observation (i.e. periodic liver tests every 6 months) is appropriate when the elevation is less than two fold elevated.  

Why recommend a liver biopsy?  I'm not recommending anything since I cannot examine you.  As I have said before, there are no hard and fast rules.  In your case, some gastros would just observe the LFTs, some would biopsy.  It depends on individual clinical judgement.  

Thanks,
Kevin, M.D.

[roxnsox]

Fatty Liver and NASH are considered mild diseases by the doctors.  At the present time there is only one treatment for these two diseases and that is low fat diet.  When I was diagnosed with NASH by the doctors at the National Institute of Health in Bethesda, MD about a year ago I decided to cut all hydrogenated oils from my diet.  This includes any item listed on a nutrition label that says partially hydrogenated or hydrogenated oil.  It took about 6 weeks before I felt better.   My cholesterol level dropped into a normal range. I also lost 20 pounds when I cut all the hydrogenated fats from my diet.  I did some moderate exercise during that time but it didn't last long because I hurt my knees.  I went to the liver clinic once a month and they checked my blood.  The liver enzymes dropped to the normal range and my cholesterol has also stayed in the normal range.  So I like to recommend that everyone cut this hydrogenated fat from their diets.  
   I have felt fatigued for years and the doctors were no help.  The National Institute of Health is doing research on NASH at the present time.  It is hard for doctors to stay current with the research that is going on all the time.  I would laso like to recommend a book called "Eat, Drink and Be Healthy", by Walter Willett.
   Good luck.

[KKIRCHNER]

Sorry Kevinmd, did not mean to inply that "you" suggeted the biopsy. I fully understand that as a MD you would need to have a closer review of me and my records to give an indepth suggestion. I was just wondering why my Gastro recommended it given that the levels are so slightly elevated.  I do understand that they may however want to cover all bases.  Still a perplexing condition that I'm not sure they will find an answer even with a biopsy.  Just a hunch on my part.

[5,6,7,8]

"...He suggested a biopsy but offered no idea as to what he was looking for, or had no idea of future treatments. This left me uneasy. ...that a biopsy is neither easy for the patient or recommended in this case. I mentioned this to him and he became indignant and said that it might be Cancer and this was the only way to find out. This left me even less impressed with his recommendation and demeanor,... Having said this I welcome your thoughts and recommendations."

...KevinMD responded well. He mentioned all of your tests & stated his explaination & suggestion,...- ALL but one, the ferritin.  Perhaps he can comment on the slightly high reading.

O.K., I WAS going to end my message at that last sentence. After reviewing it, I realize that it may sound a bit snippy to KevinMD. I don't mean to be rude - UNLESS you didn't mention the elevated ferritin on purpose.

It sounds like KKIRSCHNER is looking for a medical explaination connecting his test results to doctor's demeanor.

It sounds like KKIRSCHNER is rationalizing NOT having diagnostic testing.

I think it is of life-saving importance to spell out the reasons that KKIRSCHNER should listen to his doctor...

Often, tests are ordered to "rule out" a particular dx, based upon symptoms(pt complaint)nothing else.  This is NOT the case here.

I realize that the consistant slight elevation in ferritin is most likely insignificant. I am also aware that high ferritin is a "tumor marker"- indicating that there may be something more going on, requiring further testing.  You have already had test results that indicate further testing,...  A biopsy sounds like they're jumping ahead real fast, - that could be a good thing.  Why mess around?