Re: HCV/Ammonia Levels/Gallstones

Posted By HFHSM.D.-D.M. on April 20, 1999 at 08:56:07

Topic Area: Hepatitis C
Dear Doctor,
I am a 32 year old woman, who contracted HCV in 1981 {15yrs.old}, that was drug/Alcohol related. I have a lumen full of gallstones, and hormone difficulties. I have also been doing some reserch on my own. I am temporarily living in Thailand, but from Canada and not under any doctors supervision. In some of the tests that I have initiated on my own, one of them was an serum ammonia test. I am at the understanding that the Normal level = 9 up to 33, mine is reading 630. Now before I freek out, I have also done other tests: GGT, ALS,ALT, Total Protien, and alubim ect. all that appear to be either in the middle or normal.I have also had an ultrasound to check spleen and liver again all appear to be in the norm.
So my question is:
- What are the OTHER, if any causes for elevated ammonia levels?
- I am not taking anything for this, is that a concern?
- I am not on ant HCV treatments
- Is it possible that the gallstones are related?
- Also, if at this time I am pregant, would eleveated levels harm a fetus?
- Is it still possible that I may have a liver chirrohois problem, even though they cannot see anything on a regular ultrasound?
- I ask, as I am not sure when I shall return to civilization, as the "local" internist asked me if having 630 ammonia was a problem. SOOOOO HELP Please.
Thanking you in advance
Elizabeth




Dear Elizabeth:
I appreciated your question and your most unusual situation.  I can imagine your frustrations with where you are and your concerns about the medical advice you are getting.  Im not sure Ill be able to sort out your situation but maybe I can make some comments that might help. I will answer your questions about ammonia levels but I will stress at the beginning that I have concerns about the accuracy of your test and I am not certain if you have to worry about this issue.  
To answer your first question, elevated blood ammonia levels are almost always due to liver disease.  There are some unusual circumstances in which someone can have an elevated ammonia and a normal liver.  They include conditions such as metabolic defects and a procedure called a ureterosigmoidostomy, but it seems unlikely that you have any of these.  
As the liver fails, ammonia and other chemicals (that are typically cleared by the liver) rise in the blood.  Many patients with high ammonia levels from liver disease develop a condition called hepatic encephalopathy and develop symptoms such as forgetfulness, confusion and lethargy.  We call this hepatic encephalopathy. Surprisingly, the level of the ammonia does not always correlate with the severity of someones hepatic encephalopathy.  Some individuals tolerate high ammonia levels with little confusion whereas others will have severe problems with only mildly elevated ammonia levels.  
We typically can treat hepatic encephalopathy with medications but ironically we usually tailor the treatment to the symptoms and not to the ammonia level.  I do not know if high ammonia levels are harmful to a fetus because few women who have high ammonia levels due to advanced liver disease have children.  In those that do, the advanced liver disease in itself poses a risk to both mother and child.  It is unlikely that gallstones would contribute to the high ammonia levels.  Finally, it is possible to have cirrhosis with a normal ultrasound.  The ultrasound is not a sensitive test for early to moderate cirrhosis, in particular.  
However, first and foremost, I think you have to question the accuracy of the lab value that you obtained. This is a very sophisticated test for a lab to perform. Blood has to be obtained in a certain way, moved on ice and then analyzed relatively soon.  Was this all done in you case.  Was it done by a reputable lab at a large medical center.  Here is what I would recommend to you.  It is quite possible to get excellent medical care in a country like Thailand.  I would ask around and talk to people you trust and get the name of a reputable liver specialist preferably in Bangkok or another larger city.  Preferably, this individual would have an association with one of the more prestigious hospitals.  If nothing else, this individual could obtain an accurate ammonia level if in fact one is even indicated.  Unfortunately, I am not in a position to give you the name of a good physician in Thailand.  
Lastly, I would make a final point to MedHelp participants, in general.  An ammonia level can be a very difficult test to interpret.  I am a liver specialist with access to a quality lab and I hardly ever get an ammonia level on my patients.  I hope this information is helpful to you.  Good luck with your situation.  If you have additional information or questions, I would invite you to post the material to MEDHELP or to contact us directly at Henry Ford [phone]. We have an active group of liver specialists.
This response is being provided for general informational purposes only and should not be considered medical advice or consultation.  Always check with your personal physician when you have a question pertaining to your health.  












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