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What causes elevated liver enzymes?

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Posted on Mon, 4 Jul 2016
Question: Hello. I am a 34 year old female who is moderately overweight. I suffer from endometreosis and am currently off work due to chronic pain. I take 16mg of long acting hydromorphone and between 8-20mg of fast acting hydromorphone a day, as well as 2mg of Visanne (a progestin). My liver function tests were all abnormally high starting approximately a year ago. I also tested positive for Smooth Muscle Antibodies.
I had a liver biopsy in February of this year, and it came back normal. After the liver biopsy I began experiencing high levels of pain on my upper right flank - At its least, it feels like the stitch you get in your side when running, and at its worst, it is sharp and I can barely take a deep breath. I have had a CT scan which shows inflammation, but no answers.
I have never been a heavy drinker and don't do any drugs, and have been drinking virtually nothing for quite some time now. The rest of my liver functions have normalized, but the GGT - which is currently 224. I also have extreme fatigue, nausea, total loss of appetite and joint pain that was never present before.
I'm grasping at straws at this point...
doctor
Answered by Dr. Shruti Rijhwani (1 hour later)
Brief Answer:
Has your ANA been done ?

Detailed Answer:
Dear Madam,

Thank you for posting your query on HCM.

I have looked into your problem & I have gone through your reports, high get may be due to hormonal preparations that you re taking which may cause cholestasis . Your ASMA titre is not very significant but can't be ignored . What I get from your reports is that , and also your clinical features that you should be evaluated for Lupus which s an autoimmune disease that may give rise to all these features and autoimmune hepatitis can be a part of this . Have you ever been evaluated for same ? Please revert back to me with details .

Take care.

Dr. Shruti
Above answer was peer-reviewed by : Dr. Yogesh D
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Follow up: Dr. Shruti Rijhwani (34 minutes later)
My mother has Lupus and I was diagnosed with Celiac when I was 17. Autoimmune definitely runs in the family and is a current/present part of my world.

(I had both scopes done last October and the Celiac is completely controlled via diet with no issues)

I did see a rhumatologist who conducted some tests -at the time he felt confident in ruling out Lupus (Negative AMA) at that time.

My GI specialist is considering AIH, but after the liver biopsy came back normal - my GI's response was to "Wait and see if symptoms get worse, then we will know more."

I am considering a full hysterectomy to deal with the chronic pain from the endometriosis...but it is hard to tell what pain is coming from where - the right flank pain that is new ( from 1 month post-biopsy) is actually worse than the rest of the pain I experience every day.

The inflammation, elevated liver enzymes etc began over a year before the hormone therapy began.

Can you suggest any other tests/processes/investigations that I can try to explore with my doctors in order to get them closer to answers? I can't handle this level of pain, without a plan for much longer...
Other more minor symptoms include : Occassional extreme itchiness, I usually chalk up to the morphine... Headaches (which may be the hormones?), dark urine.
doctor
Answered by Dr. Shruti Rijhwani (14 minutes later)
Brief Answer:
Follows.

Detailed Answer:
Dear Madam,

See autoimmune disease run a very erratic course sometimes antibodies are present and no symptoms , other times vice versa . It's not necessary that picture will completely fit . Even if antibodies are negative with a high suspicion we should repeat them. Since your mother had Lupus the possibility of you having Lupus. will be very high . I would suggest you to get ANA, ENA profile , CPK, Urine r/m , lupus anticoagulant assay , anti cardio lipin antibody , anti TPO antibodies minimally . At least this much profile will be required by you .

Regarding endometriosis , if your gynaecologist suggests for surgery you can go ahead with that but please get all these tests before undergoing surgery so that if anything has to be done before we can do. as surgery sometimes precipitate life threatening Lupus complications .

Dr. Shruti
Above answer was peer-reviewed by : Dr. Yogesh D
doctor
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Follow up: Dr. Shruti Rijhwani (33 minutes later)
You're being a huge help...thank you - while sometimes it is best to hear 'nothing is wrong'...in this case, with such high levels of pain...it's nice to have someone listening enough to have suggestions...

Can you tell me... Is what you are suggesting as a possibility - would it make sense why I have had consistent mid to upper right side pain since shortly after the biopsy? The pain ranges from a dull pain to a sharp "hurts to breathe" type pain. My GP actually thought it was a punctured lung (xrays indicated not)... It just doesn't make sense to me why it would have come from/after the liver biopsy...Could that have caused this new symptom? Is that specific type of pain symptomatic of anything you can think of?

I plan to take your list to my GP tomorrow and ask him... Along with discussing it with my specialist/surgeon.

to clarify - smooth muscle antibodies are positive - but ANA is negative.
doctor
Answered by Dr. Shruti Rijhwani (5 minutes later)
Brief Answer:
Follows.

Detailed Answer:
Dear Madam,

Thank you for reverting back.

Well yes pleural puncture can occur during liver biopsy that can lead to pneumothorax , it's not that uncommon. but for that chest x Ray should be done after the biopsy when you had complained , doing it now would not be beneficial . Other possibility is pleurisy which can be a feature of lupus for that clinically you need to be examined and also CT chest needs to be done . So you clinician should Atleast consider these two aspects .

Dr. Shruti
Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar
doctor
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Follow up: Dr. Shruti Rijhwani (18 hours later)
Is it possible - based on what you have said - that if Lupus is on the table - that the persistent pain on my right side is an inflammatory response from the same?

If so, what would perspective treatments be?
doctor
Answered by Dr. Shruti Rijhwani (26 minutes later)
Brief Answer:
Follows.

Detailed Answer:
Dear Madam,

Thank you for reverting back.

Yes there is a possibility , Lupus is known to cause pleural effusions thus leading to pleurisy which when heals up results in pleural thickening which c an give rise to persistent pain . Treatment will depend on the amount of thickening and persisting inflammation if any at this time . probably steroids will be indicated.

Dr. Shruti
Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar
doctor
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Follow up: Dr. Shruti Rijhwani (58 minutes later)
How is this diagnosed? Is it possible that this is the problem - even though a CT and chest xray came back clear? What would be the next level of diagnosis? I do have an xray of my ribs booked/going on this week, as an investigation into the pain on the right side - Is it possible that may show something?

I have read other women's experiences and even with Lupus - finding that a hysterectomy was beneficial when dealing with excessive pelvic girdle pain. I understand that asking your opinion based on what limited information you have is a shot in the dark...but is this something that might help?

Also - I met with a rheumatologist once, who felt as though he could rule out Lupus based solely on the one meeting we had- and then he ordered tests in order to assist the referral I had upcoming for a gastroenterologist ... I haven't seen him since. Would you recommend requesting a re-referral back to the original? My GP is quite helpful and has, to date, been willing to try any inquiries that he thinks might turn up answers, I've been lucky...Unfortunately he is moving on and I am going to be starting over with a new doctor...
doctor
Answered by Dr. Shruti Rijhwani (3 hours later)
Brief Answer:
Follows.

Detailed Answer:
Dear Madam,

Thank you for posting your query on HCM.

Well it's not possible that either CT or chest x Ray doesn't show any findings if this problem is there . Let's see what comes in your scheduled x Ray . Hysterectomy won't benefit as such but since you are on hormonal supplements , they can be stopped after hysterectomy so that will be good sign . As hormonal treatments are known to exacerbate lupus . I think you should consider a referral again for rheumatologist as all these diseases are dynamic and can present anytime so even if in past he couldn't find out much may be this time he gets some evidence for that .

Dr. Shruti
Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar
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Dr. Shruti Rijhwani

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What causes elevated liver enzymes?

Brief Answer: Has your ANA been done ? Detailed Answer: Dear Madam, Thank you for posting your query on HCM. I have looked into your problem & I have gone through your reports, high get may be due to hormonal preparations that you re taking which may cause cholestasis . Your ASMA titre is not very significant but can't be ignored . What I get from your reports is that , and also your clinical features that you should be evaluated for Lupus which s an autoimmune disease that may give rise to all these features and autoimmune hepatitis can be a part of this . Have you ever been evaluated for same ? Please revert back to me with details . Take care. Dr. Shruti