Correct Diagnosis?

[ashleyy0919]

I have been having dull pain on my right side under my ribs for a few months. In oct 2012, my LFT showed ast- 32 alt-56 then I lost my insurance so i had to wait til June 2013 for a follow up. Ultrasound showed enlarged liver, ALT 91 AST 62, and I had 3 positive SMA tests, but negative ANA. I do have diabetes and take humulin n and I am overweight but I have been consistantly losing a few lbs/mo. I had 1 dr who thought it was autoimmune hep but i met with the specialist and he said that since I am "extremely obese" (5'5" 200lbs and falling) that it is obviously fatty liver. I dont know if I should believe this diagnosis or not. When my dr reviewed my ultrasound, she said she didnt see anything indicating that it was fatty liver.  

[ashleyy0919]

Also, my primary care dr said she would like to see a liver biopsy just to be sure, but with kaiser the specialist is the one the final decision on doing a liver biopsy or not but since he is so positive that its fatty liver, he doesnt feel a biopsy is necessary so that means no biopsy for me.

[ashleyy0919]

The specialist was a GI specialist. He was just rude to me altogether. I am 200lbs but by abdomen isnt as big as others ive seen at my weight (im a size 12, wear medium shirts) so i am thinking the ultrasound isnt too far from being accurate. Im just more curious about 3 positive SMA tests as opposed to my ast and alt levels honestly.  Thanks for your response!

[mikesimon]

I think the best course is to see a hepatologist. Really, the gold standard for diagnosing liver disease/condition is a liver biopsy. I am not a doctor but I think that dismissing AIH simply because you are obese might be a little premature. Likewise, ultrasound in obese patients is not nearly as accurate in diagnosing fatty liver as it is in normal weight individuals. Your liver enzymes are really not that far out of range that you should panic or anything like that but they do suggest some ongoing damage which should be diagnosed with as much certainty as possible.
You said you saw a "specialist' who told you because you're extremely obese you obviously have fatty liver. What type of specialist was this doctor? Fatty liver disease is one thing but it can progress and become a more serious condition - nonalcoholic steatohepatitis (NASH). I am not suggesting that this is the case with you but I am suggesting that you will be better off the sooner you involve a hepatologist in your care.

Nonalcoholic Fatty Liver Disease
"....A liver ultrasound examination is useful for confirming steatosis. Fatty infiltration of the liver produces a diffuse increase in echogenicity (a bright liver) and vascular blurring (Figure 2). Unfortunately, ultrasound cannot rule out steatohepatitis or fibrosis, and its sensitivity drops sharply when <30% of hepatocytes contain fat droplets. It also has low accuracy in obese patients. Both computed tomography (CT) and magnetic resonance imaging (MRI) studies, especially the new technique of magnetic resonance spectroscopy, are more sensitive modalities for quantifying steatosis. However, none of these imaging techniques has sufficient sensitivity and specificity for staging the disease and cannot distinguish between simple bland steatosis and NASH with or without fibrosis. Hepatic elastography is a non-invasive measurement of hepatic fibrosis by measuring liver stiffness, which is increased with increased fibrosis. Ultrasound elastography is limited in obese patients. Magnetic resonance elastography has not been shown to detect NAFLD. Elastography is currently not widely available in the US...."

http://www.clevelandclinicmeded.com/medicalpubs/diseasemanagement/hepatology/nonalcoholic-fatty-liver-disease/

I certainly don't want to alarm you and I hope that I haven't. I really want to impress upon you how important it is to get a specialist/hepatologist involved as soon as possible to insure that your condition is managed properly. If there is not a hepatologist available to you then a gastroenterologist familiar with liver disorders would be the next choice.

Good luck,
Mike