Liver Disease, Cirrhosis ... need help please

[movingforward]

35 yr old male who has been drinking 1-2 beers/night during week, 6-10/fri & sat night from age 18-33. Then past 2 yrs (stress) started drinking 6/night, 10-12/fri & sat. Began developing a small sharp random pain in my right side (midway between armpit & waist where ribs start) about 2 mos ago. Went to dr and she ordered blood work and everything normal (ALT 35, AST 21, Alk Phosph 80, Bilirubin .4, Albumin 4.9, -ve for HepC & B)

Pain cont'd so she ordered ULTRASOUND early March which indicated "HETEREOGENEOUS INCREASED HEPATIC ECHOTEXTURE MOST LIKELY FROM FATTY INFILTRATION". I then had a CT SCAN (my pancreatic duct was not visible on ultrasound from gas) which showed "PRE-CONTRAST IMAGE SHOW NO EVIDENCE FOR FATTY INFILTRATION OF LIVER" but spleen slightly enlarged 13.5cm in greatest dimension (vs ultrasound which said speen size 10.8cm).

I stopped drinking completely for 2.5 weeks and pain seemed to go away then went out for St Patty's Day and had 8-10 beers 2 nights in a row and pain appeared again 2 days later. So I stopped drinking again and haven't drank in 3 weeks.

Then, 1 week ago I had a blood test for Lyme Disease and also had Liver Enzymes done again w/results "normal" but different (ALT 50 vs 35 6 weeks prior, AST 13 vs 21, Alk Phosph 91 vs 80, Bilirubin .6 vs .4, Albumin 4.9 same). Because of potential Lyme Disease I am now taking antiobiotics (Biaxin) along with other vitamin supplements. Since I began taking medication 1 week ago pain is back and seems to be also in front upper right quadrant. I would also note that during the initial pain and before I stopped drinking i had soft and light brown/orange stool for several weeks but that went away after I stopped drinking and now stool is back to normal color.

Questions:
1. Do I have alcoholic liver disease and more importantly cirrhosis?

2. Should I be concerned that ALT and Bilirubin went up despite basically stopping drinking?  What does ALT > AST (1.5x greater 6 weeks ago, 4.5x higher last week) indicate (I have read that AST 2x greater than ALT indicates alcohol liver disease)?

3. Would taking antibiotics for <1 week cause pain to come back

4. Is it possible to have cirrhosis and have "normal" range for all liver enzyme tests

4. Is ultrasound or CT scan more reliable to see "fatty liver"

5. Is 13.5cm for spleen a risk that I have cirrhosis as enlarged spleen can be symptom (although ultrasound a few days prior said spleen 10.8cm?)?

6. Should I ask for a liver biopsy and see hepatologist?  

7. Should I stop taking the antibiotics & vitamin supplements?

Sorry for so many questions but I have been totally stressed as I regret all my drinking (who doesn't?) and now I totally FEAR that I have damaged my liver to the point where my life might be limited to see my 3 darling angel, wonderful daughters grow up and have their own kids. Please help. I WELCOME ALL COMMENTS FROM ANYONE WHO IS SHARING SIMILAR ISSUES/EXPERIENCES.   Thank you so much

[Kevin Pho, MD]

To answer your questions:
1) Alcoholic liver disease is possible.  The imaging studies do not suggest cirrhosis, however this diagnosis is normally made by biopsy.

2) ALT > AST is not-specific for certain liver diseases.  You are correct, that in most cases, AST > ALT is suggestive of alcoholic liver disease, but this is not always the case.

3) That would depend on the cause of the pain.  If antibiotics are part of the cause, then continuing them would lead to increased pain.

4) End-stage cirrhosis can lead to LFTs within the normal range.

5) Splenomegaly can indeed be caused by liver disease.  However, cirrhosis is definitively diagnosed by a biopsy.

6) That can be discussed with your personal physician.

7) Again, the continuation of antibiotics and vitamins should be discussed with your personal physician.

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_b

[Rubble]

doctor wrote:

"4) End-stage cirrhosis can lead to LFTs within the normal range."

does that mean if you have cirrhosis but are earlier than end-stage you would have elavated liver enzymes?  and if you had liver disease but not cirrhosis that you would have elevated liver enzymes?

[cantlivenotknowing]

I have had similar problems and concerns for the past 5 mos. You can see my posting/questions addressed the beginning of March. I can tell you that if you are at all concerned with alcohol being the cause of your problems, you should definitely stop drinking indefinitely. There is obviously something going on which needs to be addressed. Your enzymes are not extremely elevated and are not suggestive of an alcohol cause, but it doesn't help to continue drinking while your worrying! I have been abstinent for 5 mos. and am still reeling from upper right quadrant pain. I am still looking for a diagnosis. My enzymes have been serially normal since I quite drinking and I have not been successful in getting a biopsy done. Doctors generally will not recommend one unless you have elevated enzymes on at least 2 consecutive tests. A few things you may want to look for to determine if there may be an issue is looking at your hands. Are they red or more colored than normal? Also do you have any irregular red marks or veins on your face or torso (spider veins). I would also suggest a possible endoscopy to check for hpylori, ulcers and gastritis. Good luck and post what else you find out.

[Rubble]

cantlivenotknowing ... if your enzyme levels are normal and you've stopped your drinking, why do you want to get a biopsy?  do you have other "symptoms" of cirrhosis or liver disease?  also - the "spider veins" is that just for spider type veins or is that for all thin veins that can be on your body but don't have "spider" center?  my friend has veins on his nose bridge and around sides of his nostrils and he doesn't even drink.  thanks.

[cantlivenotknowing]

Rubble: I have palmar erythema as a result of an episode of severe illness which I would define as alcoholic hepatitis. However, I did not check into the emergency room until 2 weeks after I stopped drinking and at that point my enzymes I beleive may have gone back to normal. I did have abnormally high enzymes of 193 AST and 102 ALT back in Jan 05', suggestive of an alcohol cause. I have been ill for 5 mos. and from what I understand, one can still have substantial Cirrhosis/Fibrosis and have normal liver enzymes if the insult (alcohol)has been taken out of the equation. I beleive this to be true especially in the case of mile cirrhosis. My symptoms are abdominal discomfort, improving regularly and inconsistent stools which seem to also be correcting themselves slowly. There is no doubt that I did some type of damage which I beleive also affected my biliary system. Spider veins on the nose and face can be indicative of liver disease from what I've heard, but can also come from too much drinking and alcohols effects on ones vascular system.

[Rubble]

cantlivenotknowing - I'm sorry to hear about your situation, but I'm optimistic that you are on the right path and doing the right things to get better. I just keep telling myself that the liver can regenerate over time so hopefully I/you can see full recovery.  best of luck.

[Scatty]

I have just discovered your site and so pleased that now have a place to ask questions and hopefully clear up my thoughts.
First, my heart goes out to each one that has any type of liver failure or disease, it is not a pleasant road. I was diagnosed approximately six years ago with cirrhosis resulting from intestinal bypass surgery thirty some odd years ago----the bypass put a strain on liver causing it to become "old" before its time. I was on transplant list until we lost our employment and therefore lost our insurance resulting in me not being able to afford co-pays and recertification. But, thru my faith in God and wonderful physicians I have been able to stabilize and lead a fairly normal life. Deleting oxcillates from my diet has been a tremendous help along with Procrit which has made a world of difference and monthly B-12 injection along with a dozen other meds! My question is: Can the liver actually regenerate itself? I have heard both yes and no from others; can the liver heal itself? Also, my legs and feet "lock" into position and at times the pain is intense in my legs, what is causing this? They have tested for poor circulation and it is not that. Thank you for your time and your help---

[supercoupe]

It is extremely interesting that the time for the liver to heal is not addressed in any scientific way in any of the literature I've searched.  This appears to be a widely brushed over topic.  What a shame since there are something like 25,000 deaths per year as a result of liver disease, with many of these people potentially "curable" or at least having their odds of survival improved if they had more concrete information to base hope on.  While I can't fully articulate this position that easily, I will give an extreme example....I read Mickey Mantle once saying something to the effect....well if I knew I was going to live this long, I may have taken better care of myself.

There is such a wide variation of information that one is left to wonder.  The overall information provided appears to shout out, "just stop drinking".  But the truth is....many people just don't.  Meanwhile, they are not equipped with strategies to improve their chances.  

But first, here's some of the random facts I've uncovered during literally weeks of internet searching:

1.  Anything more than 3-4 drinks per day for male or 1-2 drinks for women is said to be very risky.  Truth is, however, many have survived lifetimes of drinking far more.

2.  Liver transplants might recommend 6 months of abstinence before and 6 months after transplant.  If this represents the extreme of liver damage and repair, why doesn't the medical community advertise that anyone who takes off 6 months from drinking has a very good chance of having a repaired liver?

3.  Time for a liver to heal after transplant could be as quickly as 6 to 8 weeks, however there is new evidence that the time may actually be more like 6 months or more to achieve +90th percentile level of healing.  There is quite a wide variation of advertised information here.  What I wonder is....it may in fact be possible to determine in a scientific way that a person with stage 2 liver disease can actually achieve say 50% liver repair after 1 month of abstinence, 70% after 2 months, etc, etc.  Yes I know I know that people are widely different, but even this type of information can be accumulated in a statistically significant way if the community really set out to do it.

4.  Only about 5% of chronic drinkers actually develop chronic liver disease and need transplants (this of course is so difficult to actually compile accurately).   This is a bottom line fact that suggests to me that statistically it is very difficult to die from alcoholism.  I'm not condoning it....please understand that....what I'm trying to say is that if this is true....it may not take much of a HEALING STRATEGY for this percentage to be signficantly reduced.

I know people that have drank at least a case of beer per week their entire lifetimes, some for over 30 years (I am 54 myself and have a dozen or so friends that fall into this category).  What appears to be a saving grace is that the drinking is accompanied by a sufficient time off that the liver is allowed to heal itself.  For instance, drinking Fri, Sat Sun, followed by no drinking Mon through Fri.  Those who I have heard that have chronic problems drank continuously at levels of well over 10 drinks per day for 5 to 10 years or so (this is through internet search of "stories told".  Larry Hagman was a classic tale in which he confessed that he drank 3 bottles of champagne during working hours (about 15 drinks per day right there) followed by perhaps another 5 to 10 during dinner/evening hours.  This went on as far as I can remember for about 15 to 20 years before he had problems.  

A strategy to stop - either on a weekly basis, monthly basis, or yearly basis might make sense.

Why can't the medical community formulate some easy guidelines for people to understand that they have to take off perhaps twice the time off drinking as the time they take drinking....thus giving their liver time to heal.  I'm not sure of course this is an adequate rule of thumb but it certainly makes more sense than not exceeding "3-4 drinks per day" ...when this might not manifest into liver disease at all or even after 30 years.

I have found literally no direct references that show alcoholics abstaining from alcohol for X amount of then went on to live normal lives for X amount of time.  Why aren't these success stories documented?  Couldn't they become wonderful success stories for other problem drinkers?  Unless there is actually substantial scarring of the liver, one would assume that even in the wide number of chronic drinkers (assuming a regular bell curve to say 2 sigma) that these people could be "saved" or have significantly reduced risk if they achieved a "safe time for abstinence".  Perhaps this time is 3 months, perhaps its 6 months.  Let's imagine that time is actually 2 months.  If so....however hard this may be for an alcoholic to appreciate and actually put into practice....the odds of one implementing this strategy might actually be significantly higher if one actually viewed it as "receiving a new liver".

I know this sounds a bit wild in scope, but I would appreciate anyone sifting through these thoughts and try and make some positive comments.  

Another thought comes to mind....I once watched a TV show from England where a doctor there said that to cure an alcoholic by complete long term abstinence is not all that reliable.  Something like 85% go back to chronic long term drinking.  She claimed that the best "modern" approach was to attempt to "control" the alcoholics daily drinking to a point that it wouldn't kill him/her.  They didn't give specifics, but perhaps taking someone from 100 to 200 drinks per week to 70 drinks per week might extend an alcoholics chances of developing chronic liver disease a substantial amount.

My overall theory is similar...I would think that a regime of either drinking followed by sufficient heal time....and/or taking off 2-3 months every year would achieve the same results.

In any case, although the apparent variation in people and tolerance is very wide, there could be strategies developed which much better arm a person to either enjoy drinking or better survive drinking.

Any comments appreciated.

[bigehill]

Supercoupe - I completely agree with your findings as I have doing a considerable amount of research on Cirrhosis.

My whole life I've been addicted to one or the other marijuana, cocain(2 years), methamphetamine(10 years), and good old stand by alcohol. I quit taking drugs at the end of the 90's and have since then become quite a drinker. Over the years while taking drugs I didn't really drink at all but I wonder if the drugs I was taking could contribute to liver damage. I had gastric bypass surgery Feb 2005 and have lost 90 lbs since. Before the surgery I was a pretty big beer drinker but after the surgery it was too painful to drink beer so I turned to Vodka. For the last few years I would say I've been drinking at least a half pint of booze or 8 drinks a night and at least double that on weekends. Last January I became very ill and had to go to the emergency room. My Bilirubin and AST/ALT values were very high as well as my iron levels. I was referred to a Gastroenterologist buy my primary care physician and was promptly told I have to quit drinking.

Well that was 2 months ago and I've slowed down quit a bit but still manage to put away 20-30 drinks over the weekend. Not much drinking during the week though, maybe 2 or 3 drinks.

I had some lab work redone a week ago and my results showed everything was pretty much normal except my AST was 21 and my ALT was 17 resulting a AST/ALT value of 1.23. From what I've been finding in my research is that a value => 1 is a sign of alcoholic liver disease.

My real question here is although my AST and ALT values are very low does the AST/ALT value > 1 indicate I have beginning stages of Cirrhosis or do the AST and ALT values need to be higher to mean anything?

I'm scheduled to see the doctor again next week but I want to have as much information as I can before I see him.

Any thoughts would be appreciated.

Erik

[cantlivenotknowing]

Erik and Supercoupe,

I enjoyed reading your inputs especially considering that this string started some time ago. If you read this, I would like to continue the string and delve into any additional information you have found on long term healing and the prospects for liver repair with abstinence. Ive been abstinent fr 8 month's. As with my drinking, I am also obessive compulsive when it comes to getting information about liver disease and healing.

One thing I have seen written about on numerous occassions in med journals etc. is that liver fibrosis/cirrhosis can regress  and move from one grade back to another. However, there is likely to be a minimal amount of fibrosis which will always be present. Another aspect of fibrosis is that once the process has started and then regressed, even with regression there is a chance that the vascular structure (small veins/arteries)will no regenerate and may have been compromised or destroyed in the fibrotic process. Once the vasculature is gone, it will not come back from what I've read and regenerating liver cells will form irregularly around the destroyed vascular structures.  Also, the remaining little bit of fibrosis which may not ever regress is enough to cause a sufficient level of portal hypertension as to cause esophageal varices and a disruption in the flow of blood in and out of the liver. This can be assessed by doppler ultrasound which would identify the width of the portal vein (anything over 13 millimeters is considered portal hypertension) and any blood flow abnormalities even in the face of good iver function tests and biopsy which may indicate no fibrosis.  

As far as cantlivenotknowing is concerned, I know a lot more now and I want to know more. I would also like to see more written about the livers ability to heal and success stories around that.