Fatty Liver..Now What?

[Stephen-K]

Ok quick history is I have Panic Dosorder 6 -7 years see previous post that goes into everything. Thought I had Esphogeal, ColoRectal, Liver cancer all to be disproven by endoscopies and colonoscopies and tests..So YES I am a hypochondriac..Only thing I ever have found out is worng with me is Hemmorhoid and Impression: Fatty Liver on US. Fattly Liver was discovered with elevated enzyme and then test looking for Gallstones as both mom and bro have had. On US they saw Fatty Liver. Since then I have been obsessed with Cirrhosis and NASH. No Inflammation was seen on US.. So here are results of tests:

07/15/2003 - following high anxiety period of 3-4 months where I went from 210lbs to 174lbs (starvation)in that time from nerves..
Glucose 91, BUN 9(6-25),Creatine 1.1(0.5-1.4), TotalProtein 7.5 (6.2-8.3),ALBUMIN 5.0(3.8-5.0),Globulin 2.5(2.0-3.8),BilTotal 1.2(0.1-1.5),ALK PHOS TOT 61(27-142),AST 42(1-45),ALT 92(1-55) CBC was all within range .

09/24/2003 – (Weight 172) following 2 week return to normal diet. Triglyceride 68(30-150),Cholesterol 181(100-200),HDL 73,LDL 94,CHOL/HDL RAT 2.5(0-4.5),LDL/HDL RATI 1.3, VLDL 14(5-40) TotalProtein 8.1(6.5-8.0),ALBUMIN HFUN 4.5(3.2-5.5),Globulin 3.6(1.9-3.9),T Bili HFUN 1.0(0.1-1.5),Bili Dir 0.2(0-0.3),ALK PHOS HFN 66(30-120),AST HFUN 36(10-40),ALT 87(12-72) ALL HEP NEG, C-Reactive NEG, SED RATE-WES 4(0-15).

12/12/2003 -(Weight 179)  following 2 month return to normal diet.Glucose 96, TotalProtein 8.0(6.5-8.0),ALBUMIN HFUN 4.6(3.2-5.5),Globulin 3.4(1.9-3.9),T Bili HFUN 0.6(0.1-1.5),Bili Dir 0.1(0-0.3),ALK PHOS HFN 79(30-120),AST HFUN 33(10-40),ALT 70(12-72),GGT 25(8-61), SED RATE-WES 11(0-15), BUN 13(5-25),Creatine 1.0(0.6-1.2),AMYLASE PANC 55(25-115),LIPASE 268(114-286),AMMONIA 19(10-47),FERRITIN 142(22-322), ANA INDEX 0.70,ANTI NUCL AB NEG, Cerulopl 21, Myocar SCR < 1:20,ProTime 10.3(8.8-11.2),INR 1.03(0.8-1.2)

TESTS DONE:
Barium Swallow 7/10/03 - NORMAL, Ultra Sound 7/24/03 - Liver normal in size measuring 14cm in lenght The liver is increased in echogenicity consistent with diffuse fatty infiltration no hepatic masses are seen and no evidence of biliary dilation:IMPRESSION FATTY LIVER. SPLEEN and PANC NORMAL, Kidney NORMAL listed as one as 9.6cm & the other 11.1cm in length., no evidence of mass or hydronephrosis, GALL Bladder is NORMAL.  Upper Endoscopy 10/15/03 - NEG, Colonoscopy 12/8/03 - NEG
NEG

Symptoms: Hard to say what is real and in my mind at this point. But most recently I have turned my attention to urine color and odor. Color is VERY yellow but when I drink a lot it is lighter...Color is not dark like tea buth rathe rclose to apple juice color..Is this normal? Also the odor is quite strong regardles of what I eat.Kidney problems?Does this warrant me going to the Dr. for 50th time this year? Also What is the final verdict on my Fatty Liver? 2 Dr. say that it is just simple Fatty Liver because no inflamation (inflammation) was seen on US and 1 Dr. says it is NASH. ALT of 70 is in range for my lab.

[Kevin Pho, MD]

There is no strict "right" urine color.  If you want further evaluation regarding this, you could ask for a urinalysis.  

Regarding the NASH/fatty liver.  The liver function tests are normal.  At this time, there are no treatments that cure NASH. The main goal of treatment is to control the conditions that are associated with NASH, such as obesity and hyperlipidemia. A preliminary study showed that people with NASH who took vitamin E had improved results on liver function tests. Additional studies will be needed to confirm this benefit. You may want to discuss whether vitamin E is a consideration in your case.  

If the liver function tests remain in the normal range, I would continue to monitor them with serial liver tests to make sure that they don't elevate.  The next step would be a liver biopsy, and I don't think that the lab tests warrant that yet.

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.

[Stephen-K]

Oh and the Internal Med Dr. and GP Dr.as wella s 99% of resources online say that Simple Fatty lIver presents with an isolated mild elevation in on liver enzyme...But GI Dr. says that the elevated Enzyme automatically means it is NASH and that I will "See Cirrohosis in my lifetime". He went on to try and comfort me by saying it would not be for liek 10-20 years and that by then there will be a pill for complete reversal that is already in testing..

EVERYTHING online say this is not the case and that only a small portion ..like 5-15% develop into Cirrhosis.. Oh by the way I am 27YEARS OLD as I forgot to post that.

So what pattern is develping above? IS the decline in ALT directly correlating to my return to nromal diet and eating habits? At onset and finding of ALT level I was starving myself eating only 1 meal a day and working out as well...End result was muscle wasting and severe weight loss... Have read this is more likely then not the cause...

How can I work this so that I can better my chances of getting passed Fattly Liver and so I can get Life Insurance...How long should I wait now?

Should I test for anything else regarding the liver?

Thx,
Stephen

[Stephen-K]

Hello Kevin.

While I appreciate your post you really failed to answer the question...In fact you are clumping NASH together with Fatty Liver when the two are in fact different ...One is completely benign condition while the other can lead to scarring due to inflamation (inflammation)...Why with no evidence of inflammation on UltraSound and with a pattern of declining ALT numbers do you not comment on the likelihood of it being NASH vs Simple Fatty Liver...What do these tests lead you to think ie. a possible diagnosis which is why I and I am assuming most people post on here..We are looking for a suggestion fo what the problem could be... So based on the tests and Lab work pattern what is it you think this could be and why?

[GI.PA]

I am going to take a stab at this one since you still want more info...I am sure Dr. Kevin will jump in with somemore.

Definitions:
fatty liver = steatosis (fat in the liver)
NASH = Non-alcoholic steato hepatitis (fat in the liver with inflammation)

Facts of your case:
*ALT ranges from 70-92, each time only being normal or slightly elevated, this would suggest very low grade chronic inflammation (favoring NASH versus steatosis, but the difference is purely acadamic).
*Hep A/B/C panel negative
*Ferritin normal essentially ruling out hemochromatosis (a iron metabolism disorder).
*Cerruloplasin normal, essentially ruling out Wilson's disease (a copper metabolism disorder).
*ANA negative argueing against an autoimmune cause to your liver number elevation.
*INR and albumin perfectly normal, these are the best indicators of liver synthetic (making protein) function and are almost always minimally elevated (INR) or decreased (albumin) with cirrhosis.  Your CBC showed normal platelets; a decreased platelet count is usually a very early sign of cirrhosis.
*Ultrasound shows a normal liver shape, some fatty texture.  No elarged spleen (which would suggest cirrhosis)

Your doctors have tested for potentially treatable causes of liver disease AND your ultrasound suggests fatty liver.  Now the only way to be sure is to do a biopsy.  BUT, that biopsy would unlikely lead to any other information already obtained.  The biopsy has a pain risk of 1:10, bleeding risk of 1:100 and death risk of 1:1000, so it is not a risk-free procedure.  Without more significantly elevated liver enzymes, I agree with Kevin and your doctors that the risk of biopsy simply isnt worth the potential information.

To answer your exact questions:
Based on the case you have presented above, the most likely diagnosis is NASH.  The chance that you have cirrhosis is near 0  The chance that you will develop cirrhosis in 30-50 YEARS is (based on the current data on NASH is around 5%.  There is no specific treatment for NASH, just slow weight loss and management of cholesterol/diabetes.  Vit E has shown some promise.

I have been following your case with your last several posts (including your colon cancer scare).  You need to look at this outside yourself.  Quoting you here "I have been obsessed with cirrhosis and NASH", "I am a hypochondriac".  You have moved from esophogeal cancer, to colon cancer and now cirrhosis.  You are 27 years old.  You would be a textbook case to have any of these disorders at your age.  Once the doctors "prove" to you that you dont have cirrhosis, I can guarentee that a new medical focus will take you over.  You need to get help with this.  Your letters clearly show obsessive compulsive tendancies and the need for psychiatric intervention.  There is no way you can be enjoying life, always thinking your cancer/terminal illness diagnosis is coming tomorrow.  For the sake of your wife and kiddo on the way (if I recall), get help with this NOW.

Erin
GI.PA
Gastro Physician Assistant

[Stephen-K]

God Bless you Erin...That was the answer I was hoping for...And I appreciate yuor kind guidance which, and try not to laugh, I can understand as I was a Psych major in college...I have Panic disorder and been off Paxil for a year... I appreciate all that you have taken the tim eto say..

I will seek counsel now,
Stephen