Why is my ALT level elevated with liver enlargement?

Question

Hello doctor,

I had elevated ALT levels between 50 and 130 for the past one and a half years with slight enlargement. Recently, I have had elevated AST levels. There is no hepatitis or inflammatory diseases, alcohol, drug use, fatty liver, or Addison's.

Liver biopsy showed inflammation, but a resolving process likely attributed to a year-long Lyme disease treatment with various pharmaceuticals, but discontinued two years ago. Liver enzymes dropped to 50 ALT, but have recently elevated to 130 ALT.

At this point, there is no known cause. I was told to continue to wait and see. I would like to take a different approach and determine if there is something my hepatologist is not seeing. The current medications are Lamictal, Gabapentin, and Trazodone. I had abdominal CT, abdominal MRI, liver biopsy, ultrasounds, and a significant amount of blood work.

Answer 1

Hi,

Welcome to icliniq.com.

You should not wait. There is a cause that is creating an issue for the liver. It is continuously damaging your liver. The cause of hepatitis in your case could be drug-induced liver injury (DILI). All these three medications are reported to cause liver injury; though this is more common with Lamotrigine (1% cases have hepatotoxicity) and less common with the other two, and only described in case reports.

To prove DILI, we need to rule out other treatable causes of liver disease. DILI is a diagnosis of exclusion. The most common causes are nonalcoholic fatty liver, alcohol, autoimmune hepatitis, hepatitis B&C, cholestatic, and muscle disorders. We need to evaluate as soon as possible to prevent further damage to the liver. First, we need to diagnose the liver disease. Secondly, we need to quantify the damage severity for prognostication.

Probable cause:

Drug-induced liver injury, NASH, and Autoimmune hepatitis.

Investigation to be done:

Liver function test, complete blood count with ESR (erythrocyte sedimentation test) and peripheral smear examination, Immunoglobin G, ceruloplasmin, ANA/ASMA/A-LKM/ASLA antibodies, TSH/T3/T4, serum iron-ferritin-total iron binding capacity, fasting blood glucose, HbA1c, CPK (creatine phosphokinase test) total, ultrasound liver, and fibroscan.

Differential diagnosis:

Drug-induced liver injury, NASH (non-alcoholic steatohepatitis), Autoimmune hepatitis, hemochromatosis, and viral hepatitis (B/C)

Treatment plan:

The treatment plan will be started after identifying the etiology.

Take a capsule of Vitamin E-400 mg twice a day.

Revert with more information to a medical gastroenterologist online