Terrified and don't know where else to turn

[Knowimcrazy]

Hi Dr., (I am scared to watch my 18 mos daughter)

I am Dave and I don't know where to turn.  I am 37m, Obese for 4 years (6'4'' 280) and have Metab Syndrm (A1c 6.3, LDL 150, HDL 33, Trig 199, Total Chol 230. BP 125/80) since 2006.  No alchol (except college) or drugs.

Do I need transplt? I have Neuropathy in my left foot (just tingling), since 01/2006.  

Since 01/08 worse sympts:
1. My Neuropathy now painful and in hands, shins, legs groin (tingling and twitching)
2. Short term memory is suffering (not sure)
3. Cut shaving and bled for 30 min
4. Severe Dry Mouth
5. Weak muscles (not sure)

Testing 01-2006-Present:
Jan 2006 AST/ALT norml, CBC normal
Aug 2006 Esoph Endoscopy, no varicies
Jan 2007 full liver tests norml
Feb 2007 full liver tests norml, CT Fatty Liver
Feb 2007 CBC, slight high WBC (12K), Absolute Neutrophils, slightly elevated (7400)
Feb 2007 CT Chest, Fatty liver
April 2007, Hematologist, blood norml
Jan 2008 AST/ALT norml, CT of Abd, normal
Jan 2008 endscpy no varicies
June 2008 AST/ALT norml, CBC norml, CT of Abd, norml
Sept 2008 Full liver tests, norml
Jan 2006-Present, Uro norml kidney function

I went to GI (Best Rep) in Sept of 2008 and he doesn't think I have NASH yet but if I don't change my ways, I could get it. He felt my abdomen and doesn't want to do Biopsy now.  Says the Fatty liver from the CT in 2007 wouldn't changd to Cirrhosis in 18 mos. We would see severe cirrhosis on recent CT of Abd.

Here my ?:

1. Could my liver be causing the symptoms I stated above (my liver and platelets tests have been normal all 3 years)?
2. Could I have NASH or Cirrhosis and have test results above? (Norml Liver Tests, no Varicies, etc.)
3. Could A1C as low as 6.3 cause strong Neuropathy and Dry mouth?
4. Reverse symptoms with better diet/workout?
5. Do you think I need transplant?  
6. If not Cirrh or NASH, what else? (Don't know where to turn :(

I can't express how much I appreciate your help,

Dave

[Thomas D Schiano, MD]

wishing you the same

[Knowimcrazy]

I really appreciate your help.  Your words will help me go through this tough time and I will do what is necessary to find out.

Have a nice holiday, you deserve it.

[Thomas D Schiano, MD]

paxil in fact is not bad the liver.  i have many patients who use it.  The biopsy has a 1;1000 risk of bleeding.  Again, if the liver is felt to be enlarged radiographically a biopsy is not a bad time idea.  if there is only fat in the liver you will not develop cirrhosis--i do not think you have cirrhosis now either. people caqn lead a lifetime with well compensated cirrhosis and not need a transplant.

[Knowimcrazy]

Interesting, well my GI Dr. felt my liver and didn't think it was enlarged in Aug 08.  However a CT Scan I had in 2-07 said I had Fatty Liver and that it was enlarged.

This is now concerning me as I have heard that after the liver enlarges, it then shrinks when it reaches cirrhosis stage.  I am very worried now that it has shrunk and that is why my liver enzymes are normal now (as the liver isn't producing as much enzymes anymore due to ESLD).

The confusing thing to me is that my enzymes were normal when the liver was enlarged in 02-07.

I just can't afford to be wrong here as I have a 18mos old daughter and I take Paxil which I have heard damages the liver.

What are your thoughts?  Should I push for the Biopsy?  Are there significant risks?  Additionally, have you seen in your experience people with NASH Cirrhosis that have lived a normal or close to normal life span without a transplant after they lost the weight and excersised?

[Thomas D Schiano, MD]

even if the liver enzymes are normal a biopsy might be indicated if the liver is enlarged in size

[Knowimcrazy]

Thank you for such a quick response! And you have really helped put my mind at ease.  I had a terrible dream last night that my daughter would have no father and you are a big help on keeping me sane.

I originally went to the GI b/c of right upper dull abs pain (under ribs) and light brown stools and was worried, but my billirubin has recently been normal.

My GI agrees with you, just eat better and exsercise and everything will be OK, it's not too late.  But as you say I have read that Enzymes aren't a good predictor.

He also seemed to indicate that if the liver enzymes aren't raised, I probably don't have NASH....but it isn't 100% which concurs with you.

I tried to get back in to see him and he won't see me as he isn't concnered.

It is just frustrating that the only way they will give you a biopsy is if Liver Enzymes are off and your liver enzymes are not a 100% indicator of what is going on, so a person is forced to be in a holding pattern.

[Thomas D Schiano, MD]

you definitely do not need a transplant.  The only way of fidning out the severity of your liver is with a biopsy.  A non-invasive marker of fibrosis such as FiBrosure can detect any fibrosis.  if there is no fibrosis you do not have to worry.  I do not think your liver is causing your symptoms.  It is possible that your diabetes is causing the symptoms, but not likely.  i would consult a neurologist to rule out sjogren's syndrome.  Please change your lifestyle and lose some weight and I think your liver will do fine.