Saturday, September 3, 2011

A Patient with Elevated Liver Enzymes

I was working in the hepatitis clinic when I went into see a new patient.  By this time I had been working in this clinic for several years.                                                                                                                                                                                                                            
I walked into the exam room and introduced myself.  The patient whom I’ll name, Carlos was a Hispanic male in his mid-30s who was sent into be seen by us in the hepatitis clinic for elevated liver function tests.  He was obese and carried a lot of extra weight on his abdomen.  He worked as a carpenter.  I took his medical history, he had type two diabetes, high blood pressure, and elevated lipids.  Based on his history I could easily have jumped to the conclusion that he had what we in medicine call, fatty liver, or NASH, which stands for non-alcoholic steatohepatitis.  But first, I needed to work him up.  I had learned to never assume anything, you always worked patients up.
Patients who have liver disease will have elevated liver enzymes.  Enzyme levels are tested by acquiring a blood test and sending it to the lab for analysis.  The lab will then give us levels of both transaminases, AST and ALT.  These are the two liver enzyme levels that we look at.  In patients who have fatty liver or NASH these two enzyme levels are typically about 2-3 times the normal value.  To totally work up a patient who has a liver disease we have to acquire all sorts of blood tests to look at their enzyme levels, iron levels, auto immune levels (which will tell us whether they have auto-immune hepatitis, a disease where the patient is attacking their own liver with their own T cells) and viral serologies to rule out chronic hepatitis B and C.  We typically also acquire an abdominal ultrasound to assess the liver size and consistency. 

After acquiring his history, and doing his physical exam, I sent him off for his blood work and abdominal ultrasound.  He came back in 3 months for his follow-up appointment. 
“Hi, Carlos, glad to see you back.  How are you doing?” I asked.

“Fine, I guess.”

I looked quizzical at him and said, “I see.  Well, why don’t you come over her and sit by the computer so that I can go over all of your test results.”

With that, Carlos came over to the computer desk and sat down.  “Okay, Carlos take a look at this, here’s your blood tests results.  All of your work-up for auto-immune disease, in other words this tells us whether your immune system is turning against your liver and attacking it, is negative.  See here, your ANA (anti-nuclear antibodies), ASMA (anti-smooth muscle antibody) are both negative.  Then we take a look at your viral hepatitis serologies and they are negative, in other words you don’t have hepatitis B or C causing your elevated liver enzymes.  You see here your hepatitis B antigen and antibody are negative.  And your hepatitis C antibody is negative.  So the next thing we look at is your iron levels.  Those tests are your ferritin, transferritin and iron saturation.  All three of them are normal.  So that means you don’t have a disease called hemochromatosis, which is just a fancy word for iron overload.  So with your telling me that you don’t drink alcohol except an occasional beer with your friends on the weekend this leaves me with believing you have what is called ‘fatty liver.’  You have the usual risk factors for it, in other words, you have high blood pressure, your lipids are abnormal, you have diabetes and you are overweight.  When we put this whole picture together your condition is what we call the ‘metabolic syndrome.’    Are you with me so far?”

“I think so.  You’re telling me that my being overweight, and a diabetic has given me a problem with my liver.”

“Well you’re partially right.  It’s not just your diabetes, but it’s also the fact that you have high blood pressure and a problem with your cholesterol levels.  They have all worked against you.  The end result is that you are depositing fat in your liver.  Over time this fat can lead to your liver failing, if we don’t get it reversed.  Do you understand that?”

“Okay, now I want to show you the results of your abdominal ultrasound, remember that was the test that you had done where they put a probe on your abdomen and moved it all around with some cold blue goop?”
“Yeah, I remember that test, and they warmed the goop up for me so it wasn’t cold.”                                                                            

“Good.  Well the results of the ultrasound show fat depositions in your liver.  So all of our blood tests and the ultrasound agree with each other.  So now we need to get these elevated liver enzymes back down to normal and keep them there, would you agree?”

“Yeah, how do we do that?”

“What lead you here was your being overweight, having high blood pressure, being a diabetic and having high cholesterol levels, in particular high triglycerides.  So to get your liver enzymes to go down we have to work at it from many angles.  The first angle is to have your start exercising by walking every day.”
“But I do a lot of walking at work, I also lift a lot of heavy wood and my equipment.  Why isn’t  that enough?”

“Well the walking and lifting you do at work is not for an extended period of time, it’s being done in short bursts.  When I talk about exercising I’m talking about an extended, continuous period of time.  I want you to walk every day for at least 30 minutes at a pace where you are slightly out of breathe.   This will over the long haul help you lose weight, I’m talking about a half a pound a week.  Then you also need to stop your occasional beer drinking on the weekends.  You can still go out with your buddies, but just drink coffee instead, or water.  Next, you need to keep your hemoglobin A1C in the 6-7 range, right now it is a little high at 7.3.  Work with your primary care physician to get that down.  Your blood pressures are fine on your current medication, and your lipid levels are fine now that you are on a statin.  I also want you to meet with a nutritionist who can go over your diet in detail to make sure that it is helping you to lose weight.  Lastly I want you to start taking 800 units of Vitamin E a day as well as 3,000 units of omega 3 a day.  Both of these are anti-oxidants and they will help your liver oxidize the fat cells by breaking them open, then you will be able to use the energy stored inside.  If you don’t like burping up fish oil, then you can freeze the omega 3 capsules and take them frozen.  This will prevent you from ‘fish burp.’  Okay, now what questions do you have?”
“That’s a lot of information, can you write it all down for me?”

“How long will it take if I do all of this before my liver enzymes will become normal again?”

“Well, we’ve done this in 30 other patients, much like yourself, and we’ve found that they normalize their liver enzymes after 1 year.  But even after the enzymes are normal, that doesn’t mean you can go back to what you were doing before.  You have to stay the course, if you know what I mean.”

“Alright, I’ll give it a try.  Where do I find this omega 3 and Vitamin E stuff?”

“You’ll find them in any of the vitamin sections of your grocery store, or Sam’s club, or your local drugstore.  They won’t cost very much, about $7 a month.  And here’s your consult for the nutritionist.  Give it to the front desk clerks and they can set up your appointment.  Come back in and see me in 3 months and I’ll get a new set of liver enzymes on you then.”

“Okay, thanks.”
At the hospital I was working at I had done some research on patients with fatty liver or NASH and we had found in the 30 patients we were tracking so far that their liver enzymes normalized after 1 year. We hypothesized that by using the Vitamin E and omega 3 (both of which are anti-oxidants) we not only oxidized the fat cells in the liver, helping the body to get rid of them, but we also helped to address their elevated triglyceride levels.   If they kept the weight off and stay on their diet and away from alcohol then fat did not re-appear in their liver and their enzyme levels stayed in the normal range. 

As with so many other diseases, having NASH or fatty liver is a chronic disease, it took years to form and create a problem with the liver enzymes, and hence it would take years to un-form and allow the liver to heal back up.  If left unaddressed, fat in the liver continues to create inflammation, which over time creates scarring, which over time finally creates a cirrhotic liver, or end stage liver disease.  And end stage liver disease can lead to liver failure or liver cancer.  So the bottom line is that fatty liver or NASH is not a benign disease. 
Within the medical literature there is not a lot of information on treatment that has shown itself to be useful in this disease.  Most physicians are only able to advise their patients to lose weight, work on their diabetes (if they are one) and exercise. 
I saw Carlos back in the clinic in 3 months.  He was doing better, he had initiated a walking program with his wife after dinner every day.  And his primary care physician note stated that he was motivated to get his diabetes under better control.  He had also meet with the nutritionist.  He had lost 7 pounds of weight.  His liver enzymes drawn that morning showed that they were down by about 10 points each, so things were looking good for him.  After 1 year his liver enzymes had normalized, he had lost a total of 35 pounds, his marriage was much better with him and his wife talking on their daily walks, and his blood pressure readings were better.  After two years of his being on the omega 3 and Vitamin E he had lost a total of 50 pounds, his body mass index was now normal, he was off of his diabetic meds except metformin, and he had been able to cut down on his blood pressure meds to just taking a small dose of one medication once a day.  So with this progress, I discharged him from the clinic and just had his primary care physician do his follow-ups. 

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