Please help me understand the liver?

[jrami]

I have been having RUQ pain since December. After 2 ER visits, I have found myself at the heels of Dr's. All of which seem to have a differing opinion. My ultra sound showed coarsened echo texture, my CT scan showed hepatomegaly, MRI showed normal. In Dec all LFT's were normal, in Jan Alt was elevated (40) and this month all labs are normal again. But I have continued to have severe pain which now is on the left side as well to the point that if I could go to the ER most nights, I would. One Dr said it was nothing, another said fatty liver. I was even told I could continue drinking if I wanted. The veins on my chest and abdomen are very blue. I am not overweight, nor have diabetes or other factors (that I know of that would put me at risk) other than I was a drinker. (Haven't drank in 2 months) since pain started. Any thoughts?

[fntn]

Yes, doctors are very reluctant to do a liver biopsy. This is due only to it being so invasive. The data it provides is amazing and is considered the gold standard that all other procedures and methods are measured against.

But your numbers aren't bad, so I wouldn't worry. Just keep checking the blood work for further excursions. Should they prove chronic, then additional stuff is in order.

[jrami]

That is kind of scary, that it could show normal but not be normal-then again, that is probably why I am so worried to begin with, as my MRI was normal and still feel like something bad is wrong. The Dr said he is not a super fan of the biopsy, I am assuming that is why he is doing all these other tests first, I have a feeling that if it comes back normal he really wont agree to a biopsy, which is what I want.
Thanks for sharing your knowledge, I continue to read, and trying to educate myself but seem to worry the more I read.

[fntn]

Yes, the sac can be pressured up against the rib region, but I can't imagine your liver being that big and not being detected as such with the MRI data.

And the Elastrogram accuracy is determined by knowing what the underlying disease is. Each disease will cause the liver stiffness to vary within a certain range for a given fibrosis stage. So not knowing what is going on means not knowing what a test data really indicates. In my case, the Elastrogram would likely show a normal liver, bit I have end-stage liver disease due to a rare condition. Doing the test provides data but I'm not sure it will tell you much?

Have they discussed liver biopsies? This is the only way to really know what is gping on, in some cases. The procedure is actually not bad. I've had a bunch (how they know I'm ESLD). It's the final ip5tion I guess, when all else fails

[fntn]

Yes, the sac can be pressured up against the rib region, but I can't imagine your liver being that big and not being detected as such with the MRI data.

And the Elastrogram accuracy is determined by knowing what the underlying disease is. Each disease will cause the liver stiffness to vary within a certain range for a given fibrosis stage. So not knowing what is going on means not knowing what a test data really indicates. In my case, the Elastrogram would likely show a normal liver, bit I have end-stage liver disease due to a rare condition. Doing the test provides data but I'm not sure it will tell you much?

Have they discussed liver biopsies? This is the only way to really know what is gping on, in some cases. The procedure is actually not bad. I've had a bunch (how they know I'm ESLD). It's the final ip5tion I guess, when all else fails

[jrami]

Wow! What a thorough answer, I am still very confused about all of this, as the pain has been pretty consistent with the exception of a few days earlier in the month.  I have completely changed my eating, and nothing but water or tea as far as drinks. I feel weak some days, exhausted others.

Talked to my Dr's nurse yesterday because the pain,  Dr ordered labs for this week as well as a MRI Elastrogram which I guess is a new test. They said labs can be normal with even the worse cases so they don't rely on them too much but just part of the assessment.

Did say about the pain that the enlargement can be putting pressure on the sac around the liver which is causing the pain on nearby nerves.
Thank you for the explanation.

[fntn]

All your doctors are mixed up about your possible hepatomegaly, based on all three imaging technologies. So I'd guess you are very likely normal (based on this), with some doctors seeing what they want to see. There is no way to be mistaken about this, especially with both CT and MRI being applied. Some other things to be concerned about is whether you have an enlarged spleen or portal vein, and again both should be assessed accurately via CT and MRI. And since you didn't mention either, I assume you're normal, which is very great of course.

Your doctors may have also mentioned that your liver doesn't feel pain - no liver nerves. So even if your liver were to be slightly enlarged, due to fatty liver, you would not likely feel this either. The coarsened echo texture is likely reflecting some mild steatosis (fat) in the liver, but this is very common and needs to progress to very high percentage levels (internal fat content, >50%) to be serious. And again this would have shown up very accurately within the in-phase/opposed-phased MRI imaging sequences - more quantifiable vs US imaging.

Cirrhotic livers also becomes nodular which shows up easily at the liver edges - kinda like bumps vs a straight line. I'm not suggesting that this was even a possibility, but since this wasn't reported, then your liver is likely very healthy.  

The only thing that may have caused you some problems would be: a low level GI infection that migrated to your liver via bile ducts, small gallstones
or gallbladder inflammation, or a cholestatic problem that is causing intrahepatic bile ducts inflammation. The imaging may or may not show this, depending on how bad the inflammation was. But your blood levels for ALP (Alkaline Phosphatase) may have drifted up the higher levels, but if your Bilirubin levels remain normal, then your doctors will tend to disregard the ALP elevation.

Skipping the drinking until the next blood test is a good idea though. This is an easy way to start crossing possibilities off the list. Any new supplements or prescription drugs? If so, you might want to touch base with your doctors.

Let us know how things go. Hopefully they get together and nail it down for you soon.

[fntn]

Forgot to mention that the Alt level of 40 is very mildly elevated, and not even elevated in some lab ranges. All of us have liver enzyme levels that bounce around a bit. I would be mostly concerned about what is causing your discomfort, and the enzymes are great clues of course.