escalating liver problems -- no answers

[debbsliver]

I am 38 YO, white F. 1982 diagnosed w. Hep A via mono. Gallbladder removed in 1997. Since 1999 have RUQ pain that changes in severity w. no indicators as to why. When RUQ is most painful I become overly fatigued, flu-like. Have been a social drinker in adulthood, 2-4 glasses white wine per week. In '99 found that ALT & GGT was slightly elevated. No biliary obstruction or explanation. Experienced an "episode" of severe joint pain in 99 that lasted approx. 2 weeks. No answer given, ANA neg. - ignored pain and physicians until fall 2003 (husband is an orthopod).  During four year period experienced flu or other illness 6-8 times a year. 2003 experienced increasing RUQ pain and continued frequent illnesses. Sought new physician who wanted to further look into elevated enzymes. Ultrasound report indicated possible fatty liver. Also primary MD indicated that I have PCOS (assumes it is a separate problem from liver issues). Stopped all alcohol and anti-inflammatorys. CT scan 2003 "revealed tiny 4-5 mm focus of non-specific low density near the anterior surface of the medial segmental of the left lobe of the liver." Started seeing liver specialist to work up all chronic liver disease.  nothing positively indicated at this time (ANA positive 1:40, speckled pattern with a serum gamma globulin level of 1.7).  Had a painful joint episode that lasted approx 5 days, combined with increased RUQ pain. AST remained normal, ALT & GGT approx 1.5X norm.  2/04 had liver biopsey - performed at site below sternum (2X-first was not sufficient) Next day, dizzy and light headed admitted to ER where found slight bleeding in tissues behind liver. Upon ER admission (28 hr. after biopsey) liver enzymes were still 1.5X norm. After filling my stomach with apple juice and contrast for the CT scan experienced excruciating pain in upper abdominal area. Admitted for observation, next day liver enzymes went to ALP -174, AST-252, SGPT-437. Still had pain in abdomen, fullness or pressure like feeling that increased in intensity with food. Released from hospital, and take weekly blood tests. Labs are starting to come down. week one ALP-144, GGT-293, AST-52, ALT-152. Pressure/pain, fatigue continued, started to limit food intake to avoid pain. week 2 (yesterday) ALP-93, GGT-162, AST-37, ALT-56.  (yippee). With this subtle victory ate full meal, pain and extreme pressure returned.
Liver biopsey results - no major damage, 2 of 10 layers indicate damage of unknown etiology? (do not have official report)
Question - (sorry so detailed but i don't believe you can make an assessment w/o all of info). Is there anything in history that leads you in one direction over another? What might have been the reason for the increase in pressure in my abdomen and problem in ER? Does the increase in liver enzymes directly related to my biopsey? if yes, why were they not high upon entering ER? Will I need another biopsey?

[Kevin Pho, MD]

Hello - thanks for your patience.

Although the liver biopsy is a comprehensive test, there is no guarantee of diagnosis - since it can miss diseased tissue.  

With a positive ANA, I would consider further evaluation for autoimmune hepatits.  This would include testing for various autoantibodies, including antinuclear, anti-smooth muscle, and/or antiactin antibodies. On occasion, antimitochondrial antibodies occur in association with antinuclear and/or smooth muscle antibodies.  These tests can be discussed with a liver specialist.

It is unclear what could have caused your ER visit.  It may be residual inflammation from the liver biopsy.  I would continue to monitor the liver function tests to ensure they continue to decrease.  

Regarding why the elevation of the liver enzymes in the ER - it is possible that they could have peaked after the ER visit, then decreased.  

I cannot say whether you need another biopsy.  If there continues to be no clear explaination and the liver enzymes continue to rise then that would be a consideration.  

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.

[blessed2times]

God can do in no time the things doctors may not beable to do.
Pray, believe God and see what happens.