Fluctuating Liver Enzymes

[dartmouth03]

Hello Dr,
I'm a 24 year old male nonsmoke and nondrinker, 5'7 133 w/ no family history of liver problems.  In late August of 2003 i started taking Restoril for sleep w/ occasional xanax (never take tylonel or other pain meds).  A month later on Sept. 7 I started taking Toprol Xl (12.5mgs) until Dec. 4.  On Dec. 4 2003 i stopped taking all medicines.  That November i started noticing that my toes were red/bluish color so we went to the doctor.  Went to rhuematologist and complete workup was negative so they said my toes were Raynaud's possibly made worse by Toprol.  My digits on my right hand also occasionally would swell up as well until just recently.  

The only thing that would show up as a blip on the radar from all my blood work was periodic elevations in my ALT and rarely AST.  I went to several Gastro doctors for complete workups and have found one that I'm currently working with.  They have done all the tests you mention on here in the archives for elevated alt's except for a liver biopsy.  The only postive tests i've had were a slightly positive ASMA at 1:40 (ANA w/reflexive negative several times). I also have had 2 normal abdominal ultrasounds. I had a normal admominal/pelvis CT Scan only w/ oral contrast but not the Dye injection. I also have normal lipids and trig.  Here are some more tests i've had.

A IgM=negative
B Surface Ag=negative
Hep B Core IgM=negative
Hep C=negative
Sed Rate-1 and 7 on second occasion
GGT-44
Iron-154 and then retest a few months later was 109
TIBC-297 and then retest a few months later was 264
%Sat-52 and then retest a few months later was 41
Ferritin-244
gene testing for Hemocromatosis were negative
Celiac Sprue testing was negative
Ceurloplasmin-33
Al Antitrpy-170
Proetin C and S normal
Protime-11.0
INR-1.0
CK serum-56
RA-neg
Lupus Anticoag. Panel-normal
Anti-Histone Antibody-normal
Ana Reflexive Ab Panel-normal
Complement C3 and C4-normal
Thyroid and Parathyroid tests-normal

The tests that have been abnormal since Sept. of 2003 are the ALT which is fluctuating from high normal to elevated.  Here are the results of just the ALT and AST b/c all the other enzymes have been normal everytime. I will include a few older results from when they were normal.

10/21/02-alt=27 ast=17
07/07/03-alt=31 ast=22
08/18/03-alt=44 ast=28

(starting taking restoril on 8/20/03 w/occasional xanax and on 9/7/03 starting taking 12.5mgs of toprol xl.  stopped all meds on 12/4/03)

09/02/03-alt=58  ast=20
11/28/03-alt=101 ast=61
12/05/03-alt=52  ast=28
12/22/03-alt=120 ast=35
01/14/04-alt=47  ast=26
02/08/04-alt=112 ast=40
02/23/04-alt=65  ast=30
04/01/04-alt=132 ast=27
04/09/04-alt=83  ast=20
04/13/04-alt=56  ast=33
04/23/04-alt=66  ast=27
04/30/04-alt=102 ast=41

as you can see the enzymes have been going up and down.  i'm having them tested weekly w/ my doctor.  just had a MRCP(gallbladder) and MRI of liver on Friday, so haven't received results. cont...

[dartmouth03]

update....my gastro called and said the MRCP of gallbladder and MRI of liver are completely normal....where do i go from here?  what's the point in having a biopsy if every single diagnostic test is normal???

[dartmouth03]

thank you Dr. for the answers...i was confused on one of your responses...

"There is a relative low titer of ASMA. They are pretty specific for antoimmune hepatits - especially in ranges greater than 1:100. In any case, if this is suspected, the biopsy would be the next step."  -  it was my understanding that a titer less than 1:40 is negative and anything between 1:40 - 1:60 is weakly positive and normally not associated w/ AIH...is that correct?  thank you.  maybe 1:100 is greater than 1:40 and i'm just not understanding the titer system:)

best,

alex

[Kevin Pho, MD]

To answer your questions:
1) You have clearly been through a pretty thorough evaluation.  Everything has pretty much been tested for and I don't have a good explaination for the fluctuating enzymes.  If the MRCP and MRI are negative, and the liver enzymes are still fluctuating above 100, I would consider the biopsy.

2) There are readings of the ALT up to 132.  I would consider the biopsy for a more definitive diagnosis.

3) There is a relative low titer of ASMA.  They are pretty specific for antoimmune hepatits - especially in ranges greater than 1:100.  In any case, if this is suspected, the biopsy would be the next step.

4) If the biopsy is negative, I would continue to monitor the liver enzymes serially to ensure they are not trending up.

5) ALT can vary with body mass as well as cholesterol levels.  They are a pretty specific indicator for liver damage.  

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.

[dartmouth03]

hello there....would you mind reading over my history and giving your opinion on whether or not i should pursue a liver biopsy at this time or continue to monitor my enzymes..as you'll read, you'll notice that my enzymes have just been fluctuating, but haven't been sustained over 100...that's where i'm confused in terms of getting the biopsy due to the fact that most gastros believe you should have it done "if" the ALT stays above 100...thanks for your help.

best

alex

[dartmouth03]

sorry for going over limit...if i need to be charged double, just let me know, it would be no problem.

i've read through all the archives and have a feel for the general info.  i just wanted to get your take on my individual situation.  i have no clue why these enzymes are going up and down and neither does my gastro.  the mri results coming next week should maybe give another piece of info.

1) i've read that you've said that if enzymes are continually over 100 for 6 months than a biopsy is considered...does that also apply to if they go up and down and aren't "continuously" over a 100?....like in my situation.

2) looking at my numbers would you recommend a biopsy in your opinion? my overall heatlh seems to be good except for the flucuating alt levels.

3) does a ASMA of 1:40 warrant more investigation?

4) what would you general approach be in my situation w/ everything turning out negative and fluactuating alt levels but not sustained?

5) does alt ezymes in blood automatically indicate liver damage or could the cells just be leaky possibly?

thank you so much!

best,

alex