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Elevated LIVER ENZYMES after fall from stairs. NASH?

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Long story...attempting to make it short. I was admitted to the hospital after falling down the stairs and hitting my head on February 8th of 2014. Had a concussion/traumatic brain injury that we have dealt with and are still dealing with. All of my blood tests came back normal, with the exception of my AST and ALT. I'm just going to write this down chronologically, because I think you'll be able to follow this easier. Prior to this, I have never had any enzymes that were high.

January 24th Was put on a drug called perphenazine for anxiety
February 8th AST 58 ALT 72
February 27th AST 63 ALT 108
March 5th Immediately stopped taking the perphenazine after doc tells me it can be toxic to liver
March 5th Liver Ultrasound Moderate to severe fatty infiltration of liver, all other findings unremarkable
March 5th Doctor told me I had NASH, based on high liver enzymes and fat found upon ultrasound NO BIOPSY EVER DONE
March 6th Freaked out for most of the day.... :o) (Generalized Anxiety Disorder will do that to ya!)
March 7th Got off my fat fanny (was weighing 190 at 5 feet 5 inches) and started exercising/eating right
April 21st AST 37 ALT 59 (According to my lab, AST now normal, ALT 3 points over limit)
July 21st AST 33 ALT 33 (Now both within range according to lab my doc uses)
November 6th AST 21 ALT 24
January 15th, 2015 AST 27 ALT 55 (top of range is 56)

My doctor is not concerned at all about this 30 point increase since it was still in range, although barely.....however, I am concerned that my ALT went from 24 to 55 in 2 months. I confess that over the holidays, I exercised much less than usual and ate a LOT of things I shouldn't have. The weekend before the test, I ate so much chocolate, it was pathetic. Over the holidays, I gained about 7 pounds back, after losing 60 pounds during 2014. I have now lost the weight again. Also, I took 400 mg. of ibuprofen about 3 times, 11 days prior to test.

My question is this....my doctor had actually thought that because my liver enzymes normalized so quickly, that she might have jumped the gun on diagnosing me with NASH. I did have moderate to severe fat in my liver and she has said that despite all of my weight loss, there is no need to do another scan, as my enzymes have been normal for since mid-last year.

Should I be concerned about this jump? Could it be the lack of exercise? The 7 pound weight gain? The poor eating? The Ibuprofen? I'm so scared that this is the start of my liver enzymes going back up out of range, which is significant of a major liver problem and that I'm not going to be around for my children.

I have totally gotten back on a good diet and am exercising (fast walking) at least an hour each day. Sorry to sound so dramatic.....my generalized anxiety disorder is really getting to me today.

One other question. My rbc count has been rising since this whole issue started as well. It is currently at 5.14. THe top of the range is 5.1 according to my lab. I will tell you that I take fish oil and flax oil three times a day, take a daily vitamin each day, 2000 mg of vitamin d each day and eat a TON of fish, nuts, dark green vegies, fruit, yogurt. And when I say fish....I eat salmon/trout pretty much every single day......tons of broccoli and asparagus, squash, etc.... My doctor told me that she wasn't the least bit concerned, as MANY healthy women have this level of rbc. My hemocrit is 43.2 and my hemoglobin is 14.4. I was NOT dehydrated when I went in. Could it be that I am just eating a lot of rbc friendly foods along with the supplements that I use for cholesterol?

Also, just thought of one more thing.....the day of my appt. and during the week before, I took a fair amt. of Xanax and Vistaril for anxiety as I was so nervous about the appt.

What could be going on here? I've read that high rbc counts can be caused by a condition called pv. I am terrified that I might have that. Can you please help me understand these results?

My doctor wrote at the bottom of the report that she was pleased with everything and that I didn't need to follow up on any of it unless I wanted to. By the way, everything else was TOTALLY normal....and all of my liver tests except for my ALT and AST have never been anything but normal.

THanks so much for your help. I am really scared.



Category: Hepatologist

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Category: Hepatologist
Dr. Ratnakar Kini is online now

Expert:  Dr. Ratnakar Kini replied 4 Days.

Hi Robin,
Thanks for posting your query at DoctorSpring.com
I am Dr.R.K and I am pleased to assist you.
Perphenazine can affect the liver. But alkaline phosphatase is more elevated than ALT. So I do not think perphenazine was responsible for the initial raise in ALT levels.
It may not be due to the 3 tablets of ibuprofen you took.
The most common cause of raised liver enzymes is fatty liver disease..
It was confirmed by the ultrasound scan done in March.
Except for the numbers in February which was nearly two times the upper limit of normal, on all the other occasions it was only mildly elevated and I would not worry about that.
You can have an ultrasound scan done again to look for fatty liver.
Your BMI is high and weight reduction is the first step in treatment in case of fatty liver (I presume you do not consume alcohol).
Your RBC is only a few thousand above the normal limits and it is not suggestive of polycythemia vera.Your hematocrit and hemoglobin are also not suggestive of polycythemia vera.
I would not worry about it.
I hope that answers your query.
Let me know if I can assist you further.

Patient replied :

Actually, my BMI is good since losing 60lbs. since last February. I weigh around 133 pounds and am 5 ft. 5 inches tall. You have definitely helped me to feel better about the minimally elevated RBC. However, is there a reason that my ALT would have risen (although still at the very top of the normal range) 31 points over 8 weeks.....from November through January? No, I do not drink alcohol at all. I had my last drink about 8 years ago, as I tended to like it too much and I didn't like the person it was turning me into. I do take several medications for my cholesterol and anxiety. Prevastatin 40mg/day, Luvox 200mg/day, Vistaril (for excema) 100mg/day, Xanax 4 mg at night and Ambien 12.5 ER at night. Many days, I don't take the Vistaril.....I only take it when my excema is really bad. I still don't understand the sudden jump in alt from 24 to 55 over November to January. Can you think of any reason? Could it be that I didnt eat right and exercise as I normally do when it's not holiday time? Is this level of ALT causing fibrosis to my liver? Can I reverse the high alt in other ways than diet and exercise? I am really confused about fatty liver....although you are right....I definitely had it last March and was told that it would take a year or two to discipate. I've been tested for HH, all of the hepatitis's, diabetes, etc.... and everything is negative. I thought that if I could reverse my fatty liver, my enzymes would go down. This is what scares me.....they jumped up so fast.....is this what happens in NASH? What if I can't stop it and it progresses to cirrhosis? Is this the process it usually takes if you are eating right, exercising regularly and have a BMI around 22? I just want to stop this increase in enzymes and I don't know how to. I don't have much more weight to lose, so will I just have to watch my enzymes continue to go up and progress into major liver disease? Sorry to sound so pessimistic. I think the reason I worry so much is that I don't have a good grasp of this fatty liver thing, and neither does my doctor. I've even seen a gi and she said just keep up the good work with the exercise and diet. (This is before the low numbers in November and the jump to January.) I think it's so odd that no other numbers are even close to being abnormal. If you could shed any additional light on this, I would really appreciate it. I guess my bottom line question for you is, is this a death sentence? Thanks so much for your help! Robin

Expert:  Dr. Ratnakar Kini replied 3 Days.

Hi Robin,
Thanks for getting back to me with more questions.
Though ALT has raised by 30 units it is still within the normal range and I would not worry about it. I would worry if it goes at least 2 times above the upper limit of normal.
If you ask me why there is a fluctuation, I would say it is probably due to exercise. Increased physical activity can increase the ALT levels. And as said earlier fatty liver disease is the most common cause for mild increase in the liver enzymes. The statin you take for high cholesterol also increases liver enzyme levels.
Your ALT does not indicate liver damage that may lead to fibrosis. Even if there is significant damage it takes decades before fibrosis and cirrhosis set in.
In a nutshell, since the fluctuation was within normal limits, there is no need to worry and it is most probably be due to exercise or the statin .

Patient replied :

Could FAST treadmill walking for 1 to 2 hours a day, 4 or 5 days during the prior week, cause this type of elevation? My appointment was on a Monday and I had exercised MOST of the days during the prior week for 1 - 2 hours a day. One in the morning and one in the evening. Enough that there is sweat pouring down my stomach and my face. I stopped on Thursday after making my appointment, but still walked for 30 minutes a day over the weekend, just much slower and did not walk on Monday morning. Everything I read talks about weightlifting increasing your ALT levels. I just want to be sure that fast walking can do the same thing. Thanks so much for your patience and help. I really appreciate it. By the way, I exercise on the treadmill due to my fatty liver most days of the week for at least an hour. Before I test the next time, should I refrain from exercising for awhile before the test? Also, when would you recommend that I retest? Will my ALT always be high if I fast walk for an hour or two each two each day....I'm thinking that I should always tell the doctor, whoever it may be, that I do that before they draw blood. Thank you again. Robin

Expert:  Dr. Ratnakar Kini replied 2 Days.

Hi Robin,
Yes Fast treadmill walking can increase the liver enzymes.
It takes at least a week for the liver enzymes to reach the baseline after stopping the exercise.
And as I told you earlier, this might be just one of the causes as statins you take for cholesterol can also raise the liver enzyme levels.
I hope that answers your question.

Dr. Ratnakar Kini
Category: Hepatologist
Fellowship - DM - TN Dr.MGR Medical UniversityResidency - TN Dr.MGR Medical University Medical School - Stanely Medical College, TN Dr.MGR Medical University
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