Still concerned about my liver!

[bcreilly89]

Hey all,

New to the group here but have been visiting for roughly 2 years as I've worried myself like crazy over some past drinking habits. To give some background: I drank heavily (roughly 8-12 beers a day) for about 4 years before snapping out of it and cutting way back. In addition, I partied like a lot of normal college kids 2 - 3 nights a week during the college years. After those 4 years, I felt some upper right quadrant pain and freaked out: quit cold turkey for 4 weeks, no withdrawal symptoms or anything. Went to the doctor and got a physical, along with blood work (while also voicing concern over my liver due to the RUQ pain). Labs all came back clear, as did an ultrasound. I resumed drinking ever since but have cut back to only on weekends and essentially well under the guidelines for maximum weekly consumption.

I still wasn't convinced, so I sought out additional opinions and more extensive blood work over the next 5 months. My Fibroscan score in August of 2017 was a 6.0, and in November of that year I went to a gastroenterologist that specialized in liver conditions. He talked through the Fibroscan, gave me extensive blood work again (GGT, iron and hep breakdowns, all that), did an upper endoscopy due to some suspicions with the continued RUQ pain, and all in all told me everything was great. The only abnormal thing in that blood work was that my AST / ALT ratio was 1.2. He wasn't concerned at all and sent me on my way.

I received a full abdominal CT scan in March of 2018 after being admitted to the E.R. for a bad bout with the stomach flu: that CT scan and bloodwork showed up completely normal. The doctors even told me my organs were in "impressive shape." It was a great sense of relief to have that deep diagnostic confirmation.

Fast forward to today, June of 2019. I've taken long breaks from drinking (5 - 8 weeks at a time) and when I return to having beers it's minimal. In addition, I've advocated for myself and get extensive bloodwork a few times a year, focusing on my liver function in every aspect. My only "abnormal" readings in my 2 blood tests this year have again been those AST /ALT ratios. At the end of March, ~1.04 and this past week, 1.1. With that, the RUQ pain has not subsided which is why I continue to get these tests and doctor visits. I'm continuously told everything is great, but I can't help but thinking there's something unfound or lurking from that total of maybe 6 years of heavy drinking. I'm only 29 and cut back a LOT when I was 27, so I keep thinking "it can't be cirrhosis, it's way too soon."

Perhaps I'm reading way too much in to the AST / ALT ratio above 1, as everything else turns out great (GGT anywhere from 13 - 22, total Protein 7.5, bilirubin never greater than .9, all other markers great). Furthermore, i'm only very slightly overweight, eat healthy, drink tons of water and primarily avoid sugar, have run a few half marathons, have good blood pressure. Any similar experiences or call-outs to enlighten me or ease my mind a bit would be appreciated! Again, I'm thinking it's way too soon and my alcoholism never got even close to the point of inducing cirrhosis, but I can't seem to figure out this RUQ thing and the AST / ALT ratio is stuck in my head.

Super thankful for anyone taking the time to read all those paragraphs, as well as any responses. You guys are all great!

Bri

[Hidden]

One of my favorite sayings is: Sometimes, when all else fails, we simply have to trust our doctors!

Minor inversions (AST over ALT) are quite common when enzymes are both in normal range. Any exercise or exertion will bump AST slightly higher, and drinking can actually lower ALT enzymes in an undamaged liver as alcohol depletes B-Complex vitamins which are required by the liver to generate normal levels of ALT enzymes.

GGT is a great indicator a minor inversion may be a false flag, as alcoholic liver damage typically pops this quite high (often into triple digits), particularly in current/active drinkers. GGT in the teens to low 20s is about as good as it gets, so no worries there.

Advanced diagnostics like ultrasound, CT & Fibroscan should easily trump a minor indicator like a trivial inversion in ALT/AST. Doctors look at the big picture of labs, imaging, signs & symptoms in forming their diagnoses, and with all the diagnostics you've had, the big picture is complete.

This said, when your liver starts talking to you (the RUQ ache), a wise man will listen! It's hard to contemplate going teetotal for life when you are young, but you've already taken great strides at moderating your intake. Keep working on this and see if you can lower your consumption even more.

[Danubian]

Forgot that silly ratio - it just causes worry and is absolutely meaningless when the values are in normal range! Mine was/is 1.3 and my liver According to ultrasound, MRI with contast, elastograpy is fine! I was neither exerting myself nor drinking- a lot of crap theories trying to justify the exceptions. As to what an inversion is, is beyond me - nothing goes minus - the ratio can be larger that one or smaller that one - I read somewhere that the normal range 0.6-0.8. Obviously my body is either a mystery to modern medical science - or there is a lot of crap out there in the internet!

[Hidden in reply to Danubian]

A legitimate review of De Ritis can be found here:

ncbi.nlm.nih.gov/pmc/articl...

Their bottom line: "We hope that this review provides the evidence that the De Ritis ratio has continued to stand the test of time and remains a useful indicator of liver disease."

Definitely not a stand alone diagnostic, but still an important piece of the diagnostic puzzle.

[Danubian in reply to Hidden]

If the reference range for de-ritis is 0.6 to 0.8, let's assume that 90% of people fall within this. Most things in nature are subject to Gaussian distribution (Bell curve). Like the size of people or weight. The mean is 0.7. So with a mean of 0.7 and assuming that 90% of people fall in the range of 0.6 to 0.8, my value of 1.3 is very many standard distributions σ away from the mean with a very low probablity - smaller than (estimated) < 0.1%. Maybe the de-ritis ratio has a "fat tail" in it's distribution - hahaha! Such a high standard deviation magnitude from the mean is certainly NOT - using your words - "minor" nor "trivial". You say that ultrasound, CT etc SHOULD trump a minor indicator like inversion of de-ritis (whatever you mean by inversion - I assume when it crosses one - for me an inversion has a different meaning - like an inverted yield curve or an inverted symbol - upside down). Why use the word "should"? are you not sure? - either they do or they don't. If de-ritis, when the values are in normal range, means one iota, then concerning such a very unlikely event as many standard deviations away from the mean, then something is 99.9% seriously wrong! So maybe I should not believe the four gastrodoctors, the MRI with contrast, ultrasound, elastography and get a series of biopsies done. Or maybe they should add a few more exceptions to the rule - like "Any exercise or exertion will bump AST slightly higher, as well as worrying about liver health - this will bump the AST SIGNIFICANTLY higher to many standard deviations beyond the mean, and also ....". We can all add to the exceptions as we go along!

[Danubian in reply to Hidden]

I cite your article:

"When medical students are first taught about the clinical value in serum transaminase estimation the name ‘De Ritis’ is usually mentioned but subsequently enzyme ratios are frequently neglected and possibly despised." Why?

"Very few laboratory reports include the De Ritis ratio and there are several reasons that could be proposed for its absence" I bet there are!

" While simple clinical decision limits have been established for the De Ritis ratio (e.g. >2.0 for alcoholic hepatitis or >1.0 for fibrosis/cirrhosis), there aren’t any generally accepted reference intervals for the ratio and indeed it is difficult to define ‘healthy’ limits for the ratio if its main application is when transaminases are abnormal".

"Difficult to define healthy limits" - no shit - real difficult!

"We have listed the various limits that have been discussed in this review in Table 2".

The de-ritis ratio decision limits are made on the basis of the conditions! So what condition you want? healthy, acute viral hepatitis, muscle disease, alcoholic hepatitis? Take your pick!

[bcreilly89 in reply to Danubian]

Thanks so much, Danubian and Metanoia! It can be tough to draw any conclusions as a non-physician from those lab studies, so I appreciate the interpretation and explanation!

It's a good point that the intense exercise can elevate AST, I know for a fact that my last blood work (this past Friday) was after a 10 hour fast, 28 days of abstinence, and I had run about 6.5 miles no less than 15 hours prior, so perhaps that caused the bump?

It's worth noting as well that my current GP is convinced I could have an alignment issue causing the pain that wraps around to the RUQ and has ordered me a thorough investigation of my thoracic spine with contrast (I would think this could possibly still take another look at my liver from a different angle?), I'll be doing that MRI in the next week but for some reason have myself convinced it won't yield much, perhaps I'm being too pessimistic. I'm considering also asking for another ultrasound to ease my concerns surrounding these >1 AST/ALT readings since my last imaging of any sort was roughly 15 months ago, although both of your insight and opinions has definitely helped put me at ease!

Thank you both again!

Bri

[Danubian in reply to bcreilly89]

You say "The only abnormal thing in that blood work was that my AST / ALT ratio was 1.2. He wasn't concerned at all and sent me on my way" If AST and ALT are in normal range, your doctor doesn't care about de-ritis. He does not consider it abnormal and nor should you!

[Danubian in reply to bcreilly89]

One last point, as Prof. Phoenix pointed out (no he ain't no professor - well not yet anyway - but he is really, really clued up), de - ritis can be used as an indicator when the ALT and AST are in the normal range, once a liver disease HAS BEEN diagnosed. Here the onus is on "once a liver disease has been diagnosed" which relates to my point above with regard to the de-ritis ratio decision limits being made on the basis of the conditions! But even considering this, it still means that for a healthy liver the de-ritis ratio is relatively meaningless with AST and ALT values within range.

[bcreilly89 in reply to Danubian]

Very helpful once again, thank you so much! I'll be visiting my GP tomorrow morning to touch base and will be going through with the thoracic spine MRI later in the week. Again, not too hopeful for findings on that one but who knows, maybe a spinal alignment issue is indeed causing pain that wraps around to the liver area.

[Hidden in reply to Danubian]

You really should write to Dr Sikaris (lead author of the paper I linked to) and report the errors you've found in his work. I'm sure he would be interested in your observations.

[Danubian in reply to Hidden]

obviously you yourself are overwhelmed with the valid points I made above and can't rebuke them! there are no errors in his work but he does not prove the significance of De-ritis with alt and Ast in normal range- indeed look at Table 2 - none of the diseases have been dignosed by de-ritis Maybe you should tell my four gastrodoctors and bcreilly's doctor that they are mistaken and should be very concerned about the dreadful de- ritis ratio! Maybe I should get myself a biopsy despite all the doctor insisting that my liver is in perfect nick! the probabality of them all being wrong and all three machines being defect is higher than my liver being OK given my de-ritis and simple mathematical statistics - hahahaha

[Hidden in reply to Danubian]

De Ritis is not a stand alone positive/negative diagnostic. I've never claimed it was and nether did the paper. It's simply a valuable "early warning" sometimes seen in routine labs, that can indicate additional diagnostics may be warranted in patients at risk for liver disease; particularly alcoholic liver disease.

When it comes to alcoholic liver disease, any form of early warning can be priceless. You don't want to wait till you're jaundiced to find you stayed at the party too long!

[Danubian in reply to Hidden]

Either De Ritis can be used as a DIAGNOSTIC tool or not. If an ultrasound, MRT with contrast sees liver damage - it is a diagnostic tool - it images liver damage/disease - no question about that - no doubt whatsover - unless a fly got squashed on the scanner head. If gamma gt, ALT and AST are seriously out of whack, something is definately not right. Can you say the same for De-Ritis? If De-Ritis aint no good on its own at diagnosing liver damage/disease, especially with normal range AST an ALT, then please tell me how can it be good together with other diagnostic methods at DIAGNOSING damage? What do you mean by positive/negative diagnostic?. A scan diagnoses a brain tumour or not - diagnostics are always positive/negative.

You say "early warning" twice - obviously this is the future. A warning is not a diagnosis. If a liver is perfectly healthy and De Ritis is "out of whack", how can this predict future liver damage - can it predict a man's future drinking habits, or whether he gets hepatitis C? Fatty liver, fibrosis and cirrhosis have been ruled out with me. Or is there another liver disease lurking out there caused by alcohol apart from fatty liver, fibrosis and cirrhosis, causing ALT to increase? If, and particlarly with ALT and AST in normal region, it is no good at diagnosing liver damage on its own, then how could it warrant additional diagnostics. Did bcreilly's doctor and my doctor request additional diagnostics? No - they were totally unconcerned as far as the liver was concerned. But I requested boatloads of additional diagnostics (against the advice of some here, e.g. Katie and Phoenix who are pretty knowledgable). My doctors thought I was paranoid - and they were right. I have been diagnosed with anxiety disorder by three gastro doctors - de-ritis didn't exactly help with that - wish I had known earlier that it is relatively meaningless with alt and ast in range. If I go back to the docs for further testing they will put me in the looney bin. I'll blame it on Metanoia

You say "it CAN indicate additional diagnostics MAY be warranted". Well that appears very vague! It may rain tomorrow! It can also rain tomorrow!.

Or are you saying that concering people with a perfectly healthy liver, a high De-Ritis ratio indicates a history of drinking? I've never heard of that one - not saying it can't be true though. Now that is a question which I would like answered. It would be interesting to know the mechansim by which AST is increased without liver damage, caused by past excesses of alcohol. If this were the case, then obviously it can predict the future to a certain extent since Mark Twain said ,"History doesn't repeat itself but it rhymes"! But hey - no one can predict the future!

Regarding your last comment, well I don't disagree with it, but it doesn't affect the facts put down by both of us here!

[Hidden in reply to Danubian]

I'll agree, if you've got a hepatologist on speed-dial, give him a call and order up an advanced diagnostic. No need for De Ritis once you've reached the specialists!

If by chance you don't have access to advanced diagnostics, there are clues to be found, even in routine labs your GP can order. We do what we can with the tools available to us at the time.

[Danubian in reply to Hidden]

You should stay with the subject and facts! Whether I have hepatologist on speed dial is neither here nor there. You appear to have downgraded de-ritis as a diagnostic tool to a “clue”. Well if I come out of the sauna and stick a thermometer up my gearbox, it is a clue that I have Ebola LOL. You are being far too generous to de-ritis. 3 of the most modern state of the art machines here in Germany have proven that de-ritis, with alt and ast in normal range, as a tool for diagnosing liver disease, is a load of CRAP. These are facts which cannot be denied, for I have seen the results with my own eyes in black and white. Or are you calling me a liar – is that it? De-ritis, with alt and ast in the normal range, is not even slightly accurate – simple natural order and mathematical statistics prove this. Next time you cite a medical paper, try to find one with wording stating that “ with ast and alt in normal range – de-ritis is an accurate diagnoser of liver disease”.

You really should write to the scientists and engineers who developed the SIEMENS (Magnetom Espree 1,5 T und Magnetom Verio 3 T) and report the errors you've found in their work. I'm sure they would be interested in your observations.

[bcreilly89 in reply to Danubian]

Thank you all once again for all of the feedback! Update as of 7/1:

New ultrasound results. Examined by a radiologist, everything came out to be "normal," however I'm finding two points of concern:

- "The liver measures 16.5cm in the midaxillary line. The hepatic parenchyma is homogenous with no focal lesions."

Wouldn't this be seen as an enlarged liver? I'm 6'4" and 210 lbs, so a bigger guy, but everything I can find says that that would be an enlarged liver? Problem? I've requested follow-up.

- "The spleen measures 12.7 x 5.9 x 12.7cm. Minor splenomegaly, although may be constitutional given symmetric bilateral renal enlargement."

Issue here too?! Again, all bloods are within range and my only symptom is that RUQ pain. Am I unnecessarily freaking out still? Thank you all!

Bri

[Danubian in reply to bcreilly89]

"The hepatic parenchyma is homogenous with no focal lesions." I am not a doctor - but I know that is good news.

[Hidden in reply to bcreilly89]

Hey there. Where do I start here lol.. No that wouldnt be considered an enlarged liver. While the "rough" rule of thumb is above 16cm for enlargment the .5 is not going to concern any doctor. Typically a radiologist wont even note a liver as enlarged unless its 18cm and above. Also when measurements are done on ultrasound there is a margin of error, this would include your spleen. Also as a fellow male myself thst is also of 6'4 I can tell you that our organs ARE going to be a bit bigger than the average mans will be. Spleens can be up to 14 to 15 cm in people our height and size. So though clinically they will note anything above 11cm as mild splenomegaly its really not of any relevance. Logic simply dictates that 11cm cant possibly be true for a 5'5 male compared to 6'4 male. A doctor will tell you this. Google will not. Unless you get into more useful types of google researching such as medical journals and studies and not the usual rubbish that comes up. I do have literature to support all this btw.

The fact that the surface of your liver is homogeneous in texture is a clear and final finding that you do not have any notable fat or echotexture to suggest any liver disease at all.

As for the mention previously of having your Deritis ratio be 1.2. This is not of any relevance if both enzymes are in normal range and you dont have any other indicator of liver disease. People seem to get really confused about the relevance of ast alt ratios. Having a 1.2 inversion is not "abnormal". In fact deritis ratios are not diagnostic whatsoever. There are merely observations noted in various types of people WITH already known liver disease. Myriads of people have 1.2 inversions and no liver disease. Really the only time it is diagnostic is in alcoholic hepatitis where the ratio is typically 3:1. But if one had alcoholic hepatitis they surely wouldnt need that ratio to know it thats for sure.

I would tend to hope that your not having such a strong bout of health anxiety over this and yet are still drinking? If drinking at all is causing you this kind of stress and worry. Stop drinking. Thats my suggestion but hey, to each his own. Good luck and most of us here would kill to get the news and results you have gotten so if I were you I'd take that and run smiling in the sun with it. Dont waste your time worrying about things that arent happening. Life's to short for that shit. While I know its easier said than done. People should spend the short lives we have on earth enjoying it as much as possible not spending it worring about what could kill us each day. Especially when no eminent danger is present. Theres time enough for death later. For now live!

[Danubian in reply to Hidden]

Phoenix - I've missed you man. Those last sentences of yours are of relevance to me too - thanks. And bcreilly89, this is the notorious "Prof." Phoenix I told you about - take note of what he says!

[Lynnylynster]

Have you ever heard of Hepatic Flexure Syndrome? You could have chronic constipation and fecal impacting. This can cause RUQ because the blockages make gas and fluid build up at the turn from the ascending to the transverse colon. I suffer from this personally 😊