High level of lever enzyms

[pankaj_chaurasia]

Hi,

During Basic health checkup of my wife , we found that her LFT was raised, she delivered a baby just 2 months back.
SGOT (AST) 70
SGPT (ALT) 238
ALKALINE PHOSPHATASE (ALP) 252
GAMMA GLUTAMYL TRANSFERASE(GGT) 148

We went for further tests, and nothing is found yet.
Can you please suggest right path for diagnosis?
Following tests has been done till now:

ANTI-HAV IGM  : negetive
HBSAG (HEPATITS B SURFACE ANTIGEN) :nonreactive
HEPATITIS E ANTIBODY (IGM) 0.26 : negetive
HCV (ANTI HCV ANTIBODY) : nonreactive
ANTI -HBC IGM ANTIBODY : negetive
pANCA: negetive

ANA : negetive
ASMA : negetive
LIVER KIDNEY MICROSOME (LKM-1) 1.39 , within range
AMA : negetive


We had already spent lot of money on tests with no clue, of what is happening.


Tanks in Advance

-Pankaj

[fntn]

Liver Elastography is a relatively new technique that is used to assess the fibrotic stage of the liver. It's good at telling the doctors who has very little fibrosis, and who has advanced fibrosis or cirrhosis. It does a relatively poor job it discerning the different mid-level fibrosis stages. So it is kind of a gauge used to determine the approximate stage of certain liver disease, but it cannot determine what the disease is.

It's not meant to provide any additional pathology information. Unfortunately, that's why it's of little use for your wife's case. The pathologists will need to actually see her liver's lobular structures/cells and any related inflammatory histology or damage in the various lobular zones. It's this type of information that will be required to finally figure out what's bothering her liver.

I think it's the proper next step and it will provide a great deal of new data. Let us know how she and you are doing. Take care.

[pankaj_chaurasia]

We went for MRCP, and every thing was normal into that.
Now doctor is asking us to go for biopsy after one more LFT.

I found one more test "Liver Elastography" which is non invasive.
can you please suggest whether it will help or not.
Our doctor is very busy and no-nonsense person, don't know how to ask her about "Liver Elastography".

[fntn]

I forgot to mention the condition known as "cholestasis of pregnancy". You've likely heard of it, and I'm sure her doctors are considering it as well. But it usually is caused by bile blockage, and her bilirubin levels are nice and low. Hopefully some new testing will shed some light on things.

[fntn]

This is a puzzle for sure. It's good that your dealing with a referred Gastro, their extra knowledge in the hepatobiliary system should help. And I would skip the ultrasound and go straight to the MRI. You should also insist that they do a MRCP as well, given that her condition definitely involves the biliary system (her elevated Alp), although without jaundice which suggests a chronic condition.

In some rare instances, Primary Biliary Cirrhosis (PBC) patients are AMA-negative. Some of these patients are true AMA-negative cases, and others become positive when they use a more sensitive testing method for AMA antibodies. You might have her doctors try the more sensitive essays.

I would want to get the MRI/MRCP done first, but keep in mind that it may not detect anything unusual since PBC patients disease conditions don't typically show up during cholangiography procedures (the disease affect the very small bile ducts, too small to visualize).

I would then followup with a liver biopsy. This maybe the only way to determine what is really going on. Liver biopsies are not done very often but your wife's case is likely one where it is deemed worth pursuing. The procedure isn't painful and the after effects are minimal. I've had a bunch of them myself and I hate needles! The amount of data that is provided to the pathologists is amazing and will likely tell the story of what's causing her condition.

The itching maybe part of the cholestatis, but this usually (but not always) affects the patients who also suffer from jaundice. Take care and let us know how she is doing.

[pankaj_chaurasia]

Thanks a lot for the response.

We are seeing a Gastro, in reputed hospital and following doctor advised test.
rest of parameters were in normal range.
BILIRUBIN TOTAL 0.4,
BILIRUBIN Direct 0.1
Total protine 7.8
Albumin 4.2
globulin 3.6
A/G ratio 1.2

Min to MAx ALP range given in report is 46 -116.

Basic ultrasound was done by the radiologist at Child berth center , but nothing unusual was detected. Later on they suggested us to refer Gastro.

Next test advised us is go for MRI scan for the liver part.
Shall we go for MRI scan or for Ultrasound first, at good radiologist?

She is having severe itching problem as well, for which doctor referred us to Dermatologist,  who told its some kind of allergy.
I am getting too much confused, and don't know whom to follow..

[fntn]

Has she been to see a hematologist yet? Or at least a GI doctor? Some primary doctors are not very knowledgeable wrt liver diseases.

Also, has she had any imaging testing done to see if there is anything unusual? Her Bilirubin (total and direct), albubin, globulin and INR levels may help, if you have the data.

They seem to have eliminated both autoimmune and viral hepatitis causes. Very strange as you mentioned. What are the min/max levels for her Alp levels (based on her testing lab printout), 252 is high wrt my labs and maybe indicating biliary issues.