Any liver/ GI specialists out there?

[TetherEndOf]

I am seeing the GP, treatment has been excellent so far (though he seems v. puzzled as things are all a bit odd) so this isn't a "ask randoms on the internet rather than go to the doc" thread, it's more of an "I'm anxious and would be interested in hearing opinions while I wait for test results" thread.

ALT is currently 191. Was up in the hundreds in summer, dropped to about 60 in Autumn, has shot back up. I had my gall bladder out last spring, initial thoughts were retained gallstones in the bile duct (symptoms seemed to fit with a stone being passed, then ALT levels went down - but now they've shot back up again).

Anyway - how bad is an ALT of 191?

And what could be causing it? I was never a big drinker (never outside NHS guidelines, in fact rarely reached that) and have basically not been drinking at all for months because of ALT levels. My BMI is below 25 (though admittedly I was a classic candidate for TOFI - "thin outside, fat inside" due to an overwhelming chocolate addiction - but again have really tried to clean up my act). Waiting for blood test results for HIV, all the hepatitises (is that even the right plural?), auto-immune markers...

Does anyone have any thoughts? And how worried/complacent should I be? I feel alright in myself for the most part - bit knackered (but that could equally be work + home schooling + normal crap life under pandemic). I do think I had an episode of cognitive impairment back in summer (that was what drove me to the GP in the first place - dropping a clanger at work so bad I thought "shit - early onset dementia?") But no jaundice or anything like that, apparently abdomen feels okay on being palpated.

Gender and age?

Female, 55.

I'm not medically trained but non alcoholic fatty liver disease is an illness that I think is not unusual. Has your GP suggested this as a possibility?

@Fairystory

I'm not medically trained but non alcoholic fatty liver disease is an illness that I think is not unusual. Has your GP suggested this as a possibility?

Yes it is something we've discussed - he seems to think it's unlikely given my BMI (I'm not sure that this alone rules it out, hence my comment in OP about being a classic candidate for TOFI!)

You are the right demographic for primary biliary cirrhosis, but it's more ALP than ALT with that disease. Autoimmune screen will look at this anyway.
I imagine your GP will look at referring you to a GP specialist, if that doesn't seem to happen once blood results are back then definitely push!

Thanks greatkinder.

It is actually the practice GP GI specialist I'm currently under. Forgot to mention - I've already had an ultrasound and everything looks structurally normal. I think the next step he has planned once the bloods are back is a referral to the GI team at the hospital.

ALP was up in earlier tests (as was ALT), but it seems to be ALT that's the source of concern at the mo.

I get the impression the GP is quite enjoying having an interesting case to deal with (and having a research scientist as a patient that he can talk to about results ) - just wish it wasn't my liver that was so interesting!

Well I am not a liver specialist but know that MRI would definitely diagnose fatty liver and perhaps can pick up bile duct issues.
Why haven’t you had it done, do you know?

The ALT “number” itself is not good or bad, it is just indicative of some problem somewhere in your insides :) can be a number of things. It then depends very much on what the problem is whether it is serious or not.

I don’t understand why instead of trying to guess it based on your blood tests you don’t do a simple and mostly definitive imaging study. If your GP doesn’t prescribe it try privately perhaps.

@Kishkashta it's very reasonable to await the full blood results including autoimmune screen before imaging, considering OP is well and stable.

@genieinthebottle I agree, unfortunately I failed to notice a clarification from the OP where she said she is being referred following further bloods (I assume if they are inconclusive the GP will refer).

My comment was mostly that there is nothing concrete to be guessed based on elevated ALT alone.

OP, it is just perhaps useful to keep in mind that MRI is gold standard of liver evaluation, so eventually if nothing becomes clear based on your blood results this should be done and will likely help to determine the cause.

PBC is uncommon. You'd have to be pretty unlucky for that.

Sometimes liver results can be weird for a while then spontaneously resolve.

There are so many possibilities it could be a long process of elimination to get a best guess diagnosis even once under a hospital team.

If you're asymptomatic but just picked this up on screening then that is usually more positive prognosis-wise - if it even turns out to be anything at all - than if you were symptomatic.

Thanks everyone - lots of interesting suggestions and thoughts to read up on.

I think the thing is initially the story all seemed to hang together - gall bladder removal in March, took a while for that to settle before I realised I really shouldn't still have pain where the gall bladder had been, ALT and ALP raised, possible residual gallstones in bile duct, ultrasound and more blood tests seemed to show things were gradually resolving, booked in for blood test in January really as a "check everything has now resolved" exercise, only it turned out the ALT had gone back up again! Hence more (and more extensive) blood tests to try to get a handle on what's going on, plus referral to the hospital (though he did talk in terms of possible liver biopsy rather than MRI - but obviously that would be the hospital's GI team's call).

I've no doubt my GP's doing all the right things - it's just all a bit confusing.

Good to know that being asymptomatic is a good thing. I shall continue on my teetotal way, trying to resist chocolate and cheese (which is actually far harder than staying "dry" - as I say, I was never a big drinker even in my student days).

(Can't rule out hepatitis yet either, I don't think - I was in China a couple of years ago, and picked up a very nasty tummy bug. Unlikely to be hepatitis, much more likely to have just been standard traveller's tummy, but I'm glad they're checking).

Not an expert but mine was in the 50s last year - regularly monitored because of meds that can elevate it. Not particularly high but it was going up. Medication was lowered and it continued going up. I started taking milk thistle and it dropped back to normal after a couple of months, and has stayed normal in spite of putting meds back to original dose. Worth a try? As you have other things going on you should probably check with your doctor first

Are you on any medication?

have you done the 'string test' (ratio of stomach circumference to height)
good that you are tested for hepatitis, esp hep e is quite common and symptomless for many.

Do you do heavy exercise - particularly weights? Liver readings can be elevated by this. My AST and ALT were raised on last tests but everything else normal and my GP accepted it could be due to exercise. We are monitoring.
www.agelessforever.net/anti-aging-news-blog/got-elevated-liver-enzymes-here-s-how-to-interpret-your-liver-function-tests

Medication - HRT (haven't come across anything on Dr Google which suggests this is a bad idea with liver conditions).

I fail the string test - waist 32", height 63". That's partly why I said I suspect I may be TOFI.

But no weight training (I did preen in the summer when the GP said "Do you run? I see from your bloods that your 'good' cholesterol is high." Unfortunately I have fallen off the wagon on that front.)

NASH is the most likely cause

Have looked up milk thistle and it looks worth following up - though as you say, best done in discussion with the doctor.

To be honest, NAFLD was my first thought too, given my life-long addiction to chocolate. As I said upthread, the doc thinks that's unlikely given my weight - I'm still not convinced though, as I fail the string test, so I think my okay BMI may be a bit of a poor indicator in this instance.

Should also add if it is NASH/NAFLD it didn't show up on the ultrasound (admittedly ultrasounds are probably a relatively crude imaging device to show up early stages of this sort of thing) - but the doc is making murmurings about a possible biopsy.

Ultrasounds are very crude indeed and it used to be in fact that MRI was as well. However recent advances in MRI imaging mean that they can be used for the diagnosis instead of liver biopsy that is not without its dangers. Additionally mri can diagnose other things such as cysts or biliary tract abnormalities which it sounds like you might have since you had your gallbladder out?

Can you tell I like MRI ...

By the way I think Nash-nafld is quite rare and don’t appreciate why you would think it’s likely...

So the bloods are back... and clear! No HIV, no Hep B or C, no auto-immune issues (all big reliefs).

Also it turns out that my AST wasn't normal, it was simply missing from the lab report, so I have to have that re-done.

But possible referral up to hospital as next step.

By the way I think Nash-nafld is quite rare and don’t appreciate why you would think it’s likely...

I didn't realise it was rare - I was under the impression (with our increasing obesity problem and crap diet as a society) that it was on the increase. (Which I guess is why I started the thread - not a medic so more than likely I've got the wrong end of the stick on a number of things.)

Other good news is that doc is of the opinion that with the levels I've shown since summer/ lack of symptoms, it's nothing serious at the moment, more something that warrants a bit of monitoring to make sure they don't miss something they should have spotted, and have it come back to bite me in the future.

I didn't realise it was rare - I was under the impression (with our increasing obesity problem and crap diet as a society) that it was on the increase.

You are actually right - nafld is estimated to be prevalent in 30 percent of the population! So I stand corrected - sorry for the confusion.

(I was thinking about NASH which additionally shows inflammatory changes - now this is something I didn't come across too often in the context of liver imaging...)