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Gastroenterology (Expert Forum)
Elevated Liver Enzymes
Answered by
Kevin Pho, MD - Internal Medicine
KevinMD.com
This forum is for questions regarding Gastroenterology issues such as Acid Reflux (GERD), Barretts Esophagus, Colitis, Colon/Bowel Disorders, Crohn's Disease, Diverticulitis/Diverticulosis, Digestive Disorders, IBS, Stomach Pain.
Elevated Liver Enzymes
by PhilMonk, Jan 10, 2007 12:00AM
My wife (43) was diagnosed with Colon Cancer in Feb 06, staged at T4-N1-M0. It was graded as 3/4 (poorly differentiated).
After surgery, she received 12 treatments of Folfox over 6 months. As the regimen neared its end, her CEA and enzymes began to rise. For the data I have here fromJune to July, her ALT fluctuated in the area of 107 to 142 (normal 5-45), AST around 78-95 (10-35) with AST/ALT <1. ALP reached 180 (25-85). Her CEA began to rise at the same time.
At the same time, she was being followed for hypothyroidism. Once we got access to a specialist, her TSH levels were close to zero. Her Synthroid dose was raised from .1mg to .112 mg.
The levels mentioned above declined with some reaching normal levels.
A CAT scan, PET scan and an MRI showed nothing wrong.
Other factors of note is that she experienced considerable weight gain (5ft 5 - gained 40 to 50 lbs to reach close to 200 lbs). It also appears that she has HNPCC. She also has had 2 bouts of kidney stones around 10 years ago.
Now her last two blood tests have shown worrying increases.
December 2006
ALP=183
GGT=140
ALT=24 (normal)
CEA=8.5
January 2007
ALP=203
GGT=145
ALT=30 (normal)
CEA=12.5
She had a CAT scan of her head this week (no results yet). On Friday, a scheduled PET scan of the liver. There is also an emergency consult with a gastroenterologist on Thursday to discuss a blind biopsy.
I am curious to know at this point is there anything we should be looking at further in terms of questions to ask and treatment options we should be pushing for.
The oncologist seems to believe that there is cancer there but I get no sense that he ever looks at anything outside of scans and liver tests. He is good at what he does, but it seems excessively compartmentalized to a very specific bailiwick.
So when we bring up the fact that hypothyroidism can cause CEA to rise, it is brushed off, especially in terms of getting blood tests and ensuring that it is being adequately treated (it is near impossible to get access to an endocronologist). I wonder about sub-clinical hypothyroidism even with her TSH levels now within the normal range (What is the interplay with T3 & T4?).
Hypothyroidism though should cause ALP & GGT to be low not high as they are now. Then I start to wonder if the dose increase to .112 mg of synthroid might be too high?
We wonder about non-alcoholic fatty liver (NAFL). Has her weight gain caused problems in this regard? Obesity can be a cause for increases in GGT.
Hence, I am looking for guidance and realism as to the intermingling of all these factors.
Elevated ALP, GGT & CEA
Why are the ALT & AST now normal?
Hypothyroidism can cause increases in CEA, but not in GGT & ALP
Do the T3 & T4 levels have any affect on the above?
Is the possibility of NAFL a realistic scenario?
If yes are there different tests that should be ordered up?
Is there anything that we need to make sure they for the biopsy?
We will appreciate any help you can offer.
Thank You.
After surgery, she received 12 treatments of Folfox over 6 months. As the regimen neared its end, her CEA and enzymes began to rise. For the data I have here fromJune to July, her ALT fluctuated in the area of 107 to 142 (normal 5-45), AST around 78-95 (10-35) with AST/ALT <1. ALP reached 180 (25-85). Her CEA began to rise at the same time.
At the same time, she was being followed for hypothyroidism. Once we got access to a specialist, her TSH levels were close to zero. Her Synthroid dose was raised from .1mg to .112 mg.
The levels mentioned above declined with some reaching normal levels.
A CAT scan, PET scan and an MRI showed nothing wrong.
Other factors of note is that she experienced considerable weight gain (5ft 5 - gained 40 to 50 lbs to reach close to 200 lbs). It also appears that she has HNPCC. She also has had 2 bouts of kidney stones around 10 years ago.
Now her last two blood tests have shown worrying increases.
December 2006
ALP=183
GGT=140
ALT=24 (normal)
CEA=8.5
January 2007
ALP=203
GGT=145
ALT=30 (normal)
CEA=12.5
She had a CAT scan of her head this week (no results yet). On Friday, a scheduled PET scan of the liver. There is also an emergency consult with a gastroenterologist on Thursday to discuss a blind biopsy.
I am curious to know at this point is there anything we should be looking at further in terms of questions to ask and treatment options we should be pushing for.
The oncologist seems to believe that there is cancer there but I get no sense that he ever looks at anything outside of scans and liver tests. He is good at what he does, but it seems excessively compartmentalized to a very specific bailiwick.
So when we bring up the fact that hypothyroidism can cause CEA to rise, it is brushed off, especially in terms of getting blood tests and ensuring that it is being adequately treated (it is near impossible to get access to an endocronologist). I wonder about sub-clinical hypothyroidism even with her TSH levels now within the normal range (What is the interplay with T3 & T4?).
Hypothyroidism though should cause ALP & GGT to be low not high as they are now. Then I start to wonder if the dose increase to .112 mg of synthroid might be too high?
We wonder about non-alcoholic fatty liver (NAFL). Has her weight gain caused problems in this regard? Obesity can be a cause for increases in GGT.
Hence, I am looking for guidance and realism as to the intermingling of all these factors.
Elevated ALP, GGT & CEA
Why are the ALT & AST now normal?
Hypothyroidism can cause increases in CEA, but not in GGT & ALP
Do the T3 & T4 levels have any affect on the above?
Is the possibility of NAFL a realistic scenario?
If yes are there different tests that should be ordered up?
Is there anything that we need to make sure they for the biopsy?
We will appreciate any help you can offer.
Thank You.
Doctor's Answer
by Kevin Pho, MD, Jan 10, 2007 12:00AM
, Jan 10, 2007 12:00AM
To answer your questions:
1) The ALT ans AST can fluctuate depending on what is causing the rise in enzymes.
2) I am not aware of the thyroid levels significantly affecting the LFTs. If the TSH is within normal limits, there is an appropriate dose of thyroid medication.
3) NAFL disease is possible - but this would have been suggested on the imaging studies that were done.
4) I agree with the liver biopsy as the next step.
5) I think that the workup thus far has been comprehensive and appropriate. Repeating the PET scan to evaluate for metastases and obtaining the biopsy would be my suggested next steps as well.
These questions can be discussed with her gastroenterologist.
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_
1) The ALT ans AST can fluctuate depending on what is causing the rise in enzymes.
2) I am not aware of the thyroid levels significantly affecting the LFTs. If the TSH is within normal limits, there is an appropriate dose of thyroid medication.
3) NAFL disease is possible - but this would have been suggested on the imaging studies that were done.
4) I agree with the liver biopsy as the next step.
5) I think that the workup thus far has been comprehensive and appropriate. Repeating the PET scan to evaluate for metastases and obtaining the biopsy would be my suggested next steps as well.
These questions can be discussed with her gastroenterologist.
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_
The biopsy, if they agree to do it, will remove any doubt, at least for the liver.
I have read on several occasions that hypothyroidism can:
Raise CEA
Raise AST
Lower ALP
Lower GGT
Thank you again