Just had a LIVER MRI. I see hepatologist (1st time) June 19 2023 but the GP just scripted the MRI NOW due to other issues including high ferritin. With negative(DNA for)hemachromatosis and normal iron saturation but fatigue and erythrocytosis/hemoglobin & FATTY ...the suspicion was iron overload in heart (cardiac MRI just ruled that out) OR in liver (hematologist suggested liver MRI performed locally).
SO I was just looking at the radiologist MRI report trying to learn more now b4 June 19. It said moderate to acute NASH 19% fraction etc, but said nothing abt IRON. I noted the script from GP said "reason for MRI=elevated liver enzymes" wish it also said High ferritin (4 x over 800) and suspected iron overload.
I googled-aplenty and learned detecting IRON quantity in a LIVER MRI is complex and if you also have fattydeposits/NASH) its even more difficult, especially if you are not looking for it. But its not like i can call radiologist and ask if he didnt (or did) look for it, sigh.
Does anyone know if the results of iron quantification (overload in liver) would have been reported out by the radiologist in due course even if not explicitly asked about?
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I have hemochromatosis and when I have had an MRI they have only quantified my iron if the doctor has expressly requested it. When it is quantified, they give you usually a value in micro/mol of iron in the liver. Normal values being less than 36 μmol Fe/kg. In my case, 90 μmol, which is 100% suggestive of overload and hemochromatosis.
Ferritin can be elevated by viral or inflammatory processes. It is a complex subject. Hemochromatosis usually increases transferrin saturation, in my case 45%-50% and for example another c282y homozygous partner with hemochromatosis 47%.
Thanks so VERY much and GOOD LUCK TO YOU. so... The Hematologist (looked for PV but decided erythrocitosis) suggested a LIVER MRI be done to quantify the iron in liver, but that was not in the GP's request. I appreciate GP ordered it for me when I said i wish I didnt have to wait to see the hepatologist in 3-4 months to get a liver MRI done. he said "oh I can/will do it", but (i see) he just put "reason for MRI elevated liver enzymes" when he was well-aware of my high ferritin and other related issues. Several specialists explained the ferritin/inflammation complexities so im well aware, and again, just Im just a carrier/negative DNA for hemochromatosis, thus far.
Iron saturation stuff is totally normal, and cardiac MRI and FibroSCAN didnot indicate iron deposits/overload, and there is no mention of IRON or micro/uMol etc in this weeks radiology report on the liver MRI. Just said "diffuse loss of signal within the hepatic parenchyma" (19%FF) leads to conclusion of moderate steatosis but lookout/monitor for acute(NASH). But i read same liver MRI finding can be an indicator of iron overload. I messaged my GP that maybe he could ask radiologist to quantify iron after the fact, from the picture/scans, but dont know if thats even possible, and no replies yet. Thanks again!
I am only a carrier of one hemochromatosis gene and I have developed the disease (1200 ferritin with 38 years old), this topic is very controversial. It is an important point that you have normal saturation.I also developed fatty liver, but it seems more a consequence of being overweight, cholesterol and the stress of the liver itself with hemochromatosis. I have improved my fatty liver with weight loss and exercise.
I hope they can quantify the iron in your liver, it's better to be safe. Good luck with it and thanks to you too.
Hello. I have cirrhosis with iron overload and low platelets.. 59. Although I have had mri and every six months get ultrasound and bloodwork, I just assumed it was the blood work that showed that. Like you, I am good with everything else. I hope you find your answers.
Thank you and good luck. Some results suggested Fib-4(nearing cirrhosis) but others did not. This may not be unusual for someone with Gilbert's (like me.) While I have seen some digestive and blood specialists, my first "real" hepatologist" visit is June 19th at U of FLA.
Along the way, with regularly high Ferritin (over 600 since 2018) they suspected iron overload and/or hemochromatosis, especially with my fatigue and bloodwork (although platelets and such 194/ok.) It's very complicated but it's not apparently a hand-in-hand thing for sure (Ferritin = Iron overload = hemochromatosis).
My iron saturation is normal, so they looked to iron deposits "somewhere". Cardiac MRI was clean, so with elevated liver enzymes and confirmed fatty liver approaching acute (per CT and FibroScan) they referred me to hepatology. But meanwhile the GP ordered a liver MRI, largely because the UFLA hematologist said "ask your local doctor to order a liver MRI to check for excess iron, if yes, donate blood, etc." And I got the result last week.
Apparently because only elevated liver enzymes was specified, the radiologist/MRI did NOT quantify iron content. Some findings could mean that, but they seem to have just evaluated it, best as I can tell, as near acute FATTY->NASH. Ferritin still unknown cause, and my DNA test was negative for hemochromatosis, as were some other tests (for Wilson's, etc.)
My GP finally replied by email today regarding my inquiry abt why iron overload (or ferritin) wasn't targeted (in MRI.) He basically said something abt "well, ferritin is a no-brainer, but just get the MRI report to your June 19th visit and see what the big dogs think." Sigh.
Referring to "Some results suggested Fib-4(nearing cirrhosis) but others did not. This may not be unusual for someone with Gilbert's (like me.)"
1. Fib-4 is better to rule out than to confirm severe fibrosis .
2. There is no correlation with Gilbert's syndrome and any liver damage/disease -> "it does not pose a threat to health and does not cause complications or an increased risk of liver disease"
3. Of course if you have Gilbert's syndrome you can have some other liver disease like NASH and many others.
Fib-4 is best in HCV and HBV patients, also NASH. For other rare diseases like Wilson's, autoimmune, cryptogenic not so good. About ruling out PPV was not so high in many studies.
According to this study, Fib-4 was consistently low in in 50% of those tested with severe liver disease. I think I misunderstood your first point--a high Fib-4 can be a strong indicator to rule in fibrosis, but a low Fib-4 cannot rule it out.
See "Table 3. Test characteristics of individuals defined as intermediate or high risk on the second (final) measurement and those defined as high risk on both tests."
All risk group have very low PPV 2.0, 9.2, 13.2, while NPV very high 99. So it is exactly true with "Fib-4 is better to rule out than to confirm severe fibrosis".
Also from this article:
"The absolute risk of incident severe liver disease was low (below 2%) in individuals that were classified as low or intermediate risk at any of the tests; in contrast, the absolute risk was considerably higher (from 6–13%) in those defined as high risk at either of the 2 tests. This observation suggests that those classified as high risk should be referred for additional evaluation to verify the ‘high risk’ classification."
About 50%, I think it was in general population (which in fact not so good as screening test as single test).
"Based on these data, it seems likely that, in the general population, adding a second measurement of FIB-4 can enhance the identification of individuals at risk of severe liver disease later in life. The absolute risk of severe liver disease in individuals classified as low or intermediate risk at both tests, however, was below 2% within 27 years of follow-up. And we previously showed that the risk of severe liver disease within 5 years is very low in those at low (0.18%) or intermediate risk (0.38%) per the FIB-4.8 "
I have also asked Chat-GPT 😀
Question: Fib-4 is better to rule out than to confirm severe fibrosis. Is it true?
Answer: "Yes, that's correct. The FIB-4 index is a non-invasive tool that is commonly used to assess the degree of liver fibrosis (scarring) in patients with chronic liver disease, such as hepatitis C virus (HCV) or non-alcoholic fatty liver disease (NAFLD).
Studies have shown that the FIB-4 index is better at ruling out advanced fibrosis (stage F3-F4) than confirming its presence. In other words, if the FIB-4 score is low, it is highly likely that the patient does not have significant fibrosis. However, if the FIB-4 score is high, it does not necessarily mean that the patient has advanced fibrosis, as other factors such as inflammation and liver damage can also contribute to elevated FIB-4 scores.
Therefore, the FIB-4 index is most useful as a screening tool to identify patients who are unlikely to have advanced fibrosis, rather than as a diagnostic tool to confirm the presence of fibrosis. Patients with low FIB-4 scores can be reassured that they are at low risk of advanced fibrosis and may not require further testing, whereas those with high FIB-4 scores may need additional evaluation with imaging or liver biopsy to confirm the presence and stage of fibrosis."
Chat-gp has some good info to that effect info including "There is limited research on the accuracy of FIB-4 for assessing liver fibrosis in people with Gilbert's syndrome. However, some studies have suggested that elevated levels of bilirubin, which is a hallmark of Gilbert's syndrome, may artificially lower the FIB-4 score, potentially leading to an underestimation of the degree of liver fibrosis."
In my case, some tests and calculations arrived at a FIB-4 score giving high indication of acute fibrosis under way; other tests gave a much lower Fib-1 or2 result. Due to my Gilbert's, they reserved diagnosis and followed up with a FibroScan, CT and then MRI of abdomen, and some other things. Prominent findings were high ferritin and moderately fatty liver, but which was high enough that with elevated liver enzymes, posed a potential case for NASH.
For this and other reasons (incl. erythrocytosis and fatigue and hemoglobin) a focus on iron overload and/or some variation of hemochromatosis was suspected. With iron saturation normal, they looked to the liver content, and as per my original question, the radiologist (reporting on the liver MRI) did not quantify the iron as we wished to know while awaiting my hepatology consult in 3 months. Helpful reply above suggested doctor should request it.
Chat-gp is wrong about FIB-4 and Gilbert's syndrome. FIB-4 calculates: age, AST, ALT, Platelet count. According to all studies they are within normal range when you have Gilbert's syndrome. In fact it is a definition of Gilbert's syndrome (normal LFT besides bilirubin). So how can it lower FIB-4? Do not always trust Chat-gp , it can be wrong
Well interesting I have asked Chat-GPT:
Question: Has Gilbert's syndrome any impact on FIB-4 ( Index for Liver Fibrosis)?
Answer: "There is limited research on the relationship between Gilbert's syndrome and FIB-4 specifically. However, some studies have investigated the impact of Gilbert's syndrome on liver function tests, including AST and ALT levels, and have found that these levels may be slightly elevated in individuals with Gilbert's syndrome. This could potentially affect the FIB-4 score, as AST and ALT levels are included in the calculation. However, the degree of impact is likely to be small, and further research is needed to fully understand the relationship between Gilbert's syndrome and FIB-4."
It is more logic answer. However that's pretty surprised information about function tests and Gilbert's syndrome. I have found some limited info about slightly decreased platelet count. But nothing conclusive.
Here this study (according to chat-GPT):
"Certainly! Here is a study that investigated the impact of Gilbert's syndrome on liver function tests:
Title: Serum liver enzymes in Gilbert's syndrome: A systematic review with meta-analysis
Authors: Kanwalpreet Kaur, Nirav Pipaliya, Jaspreet Singh Gujral, Prashanth Rawal, Vipul D. Yagnik, and Prabha Sawant
Journal: Journal of Clinical and Experimental Hepatology, volume 7, issue 4, pages 342-347, 2017
In this study, the authors conducted a systematic review and meta-analysis of previous studies that investigated the association between Gilbert's syndrome and liver function tests, including AST and ALT levels. The analysis included nine studies with a total of 1,257 participants. The authors found that individuals with Gilbert's syndrome had slightly higher levels of AST and ALT compared to individuals without the condition. However, the degree of elevation was generally mild and not clinically significant. The authors concluded that Gilbert's syndrome is unlikely to cause liver damage or affect liver function in a clinically significant way.
Also:
Certainly! Here are a few studies that have investigated the impact of Gilbert's syndrome on liver function tests:
1. Jendrzejczak et al. "The influence of Gilbert syndrome on liver function tests." Hepatology Research. 2003 Oct;27(2):92-6. doi: 10.1016/s1386-6346(03)00125-6.
2. John et al. "Effect of Gilbert's syndrome on liver function tests in Indian population." Indian Journal of Clinical Biochemistry. 2014 Jan;29(1):76-80. doi: 10.1007/s12291-013-0374-y.
3. Peng et al. "Elevated alanine aminotransferase and decreased platelet count in Gilbert syndrome." PLoS ONE. 2018 Mar 22;13(3):e0194801. doi: 10.1371/journal.pone.0194801.
These studies suggest that individuals with Gilbert's syndrome may have slightly elevated levels of liver function tests, including AST and ALT, and lower platelet counts. However, the clinical significance of these findings is generally considered to be minimal, and Gilbert's syndrome is not typically associated with significant liver damage or fibrosis.
But I think general the impact is not well described in many studies. Any when I regenerate if there is any impact is described as minimal.
Anyway good luck. One more thing. Have you confirmed your Gilbert's syndrome with genetic test?
Perhaps it is more anecdotal than scientific revealing, but that was my situation, as I am confirmed with Gilbert's many years. When enzymes were recently elevated, some testing including some FIB-4 tests showed Fibrosis at level F4. Besides differing results on different dates, because I had Gilbert's "known to affect such results at times in some" i went for FibroSCAN and CT and MRI and all showed more like level F1 or F2 than F4... conclusion seems to be in my case (some of) the FIB-4 results were a sort of false Gilbert's effect.... maybe, lol.
(oh, ive had so many DNA tests over the decades i dont recall (or have all records) if one showed Gilbert's, which has been on my ticket for 20+ years. I may not have had a Gilbert's-DNA done, especially if it wasn't a settled tool 25 years ago.)
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