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Anthony Bray, MD
Anthony Bray, MD, Doctor
Category: Health
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Experience:  14 years as clinician in the field of Family Practice
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latest results of a further liver function test along with tests

Resolved Question:

After a diagnosis of steatohepatitis my 24year old daughter is now undergoing tests for hepatomegaly which I believe is quite distinct from steatohepatitis. Having read about hepatomegaly it seemed to make more sense with the associated abdominal pain and that it is an under recognised hepatic condition of diabetes mellitus. We now await the latest results of a further liver function test along with tests for CMV, TSH, GGT, AST, FBC, and Antitrypsin phenotyping. If the liver blood tests fail to settle her consultant of gastroenterology will be referring her to the metabolic hepatologists. What is likely to happen on referral?
Submitted: 3 years ago.
Category: Health
Expert:  Anthony Bray, MD replied 3 years ago.

Anthony Bray MD :

Hello!

Anthony Bray MD :

Steatohepatitis(or fatty liver) is indeed associated with an enlarged liver.

Anthony Bray MD :

Diabetes may be associated with steatohepatitis as diabetes alters the metabolism of fats and cholesterol as well. There is a strong association with steatohepatitis and elevated triglycerides (which are in themselves a combination of fat plus sugars)

Anthony Bray MD :

Elevated triglycerides over time causes too much fats to be reabsorbed in the GI tract along with bile acids and these are returned to the liver. This over time causes the liver to store too much fat and it does cause enlargement of the liver.

Anthony Bray MD :

This condition may cause elevation of liver function tests.

Anthony Bray MD :

If she drinks alcohol this is another possible reason for the condition.

Anthony Bray MD :

Treatment for steatohepatitis should be based largely on an improved diet. Reduced sugars and low fat diet helps.

Anthony Bray MD :

There is also benefit from using a certain class of cholesterol, reducing medications which are referred to as bile acid sequestrants. These meds include Welchol, Questran, and Colestipol as examples.These medications work by binding bile acids and fats and eliminating them through the GI tract and reducing their reabsorption by to the liver. Over time this treatment benfits fatty liver.

Anthony Bray MD :

There are different possible causes of an enlarged liver but I think that fatty liver changes would be more likely at her age. (vascular congestion from congestive heart failure would be another possible cause of an enlarged liver for example but this would seem much less likely at her age for example)

Anthony Bray MD :

The blood tests are the most common and first line method of evaluating problems of the liver. Imaging studies may complement the picture. In some cases it may be necessary to perfoorm a liver biopsy but this is most often not necessary.

Anthony Bray MD :

I hope this information helps. If you have further questions then let me know and I wiull be happy to get back with you. If my answer has been helpful and to your satisfaction then please remember to press the "ACCEPT" button. Thank You and Best regards,

Anthony Bray MD :

Anthony Bray MD

Customer:

Thank you for your detailed information which was much appreciated. Reference to alcohol my daughter does not drink at all. She also underwent a liver biopsy after 2 ultrasounds and several blood tests. It took approx 12months for the initial diagnosis of steatohepatitis. Due to serious abdominal pain for several months she has learned to cut fat out from her diet almost completely although had always been a healthy eater of daily salads and fruit having been a keen ice skater for 10years and often took part in fun runs. She now works full time as a paediatric nurse on 13hour shifts and is feeling very fatigued.

Customer:

Thank you for your detailed information it was much appreciated. Reference to alcohol my daughter does not drink. She has always followed a healthy diet and been fairly active. After undergoing 2 ultrasound scans and several blood tests a liver biopsy was carried out and steatohepatitis was mentioned. It seemed to take 12months to reach this diagnosis after irregular blood tests and a couple of hospital admissions following viral infections. We are aware her immunity seems low although was told it was not autoimmune disease. She is now following an almost fat free diet to keep the abdominal pain at bay and is in a nursing career consisting of 13hour shifts which leaves her in a permanent state of tiredness. I obviously get quite concerned for her especially living away from home and can only keep telling her to eat well and take her insulin which I suspect doesn't happen as it should especially whilst working. I believe the condition is reversible but how much can the liver take with all this abnormality?

Anthony Bray, MD, Doctor
Category: Health
Satisfied Customers: 6547
Experience: 14 years as clinician in the field of Family Practice
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Customer: replied 3 years ago.
Thank you for your detailed information it was much appreciated. Reference to alcohol - my daughter does not drink. She has always followed a healthy diet and been fairly active. After undergoing 2 ultrasound scans and several blood tests a liver biopsy was carried out and steatohepatitis was mentioned. It seemed to take 12months to reach this diagnosis after irregular blood tests and a couple of hospital admissions following viral infections including gastroeneteritis. She seems to have a low immunity although was advised it was not autoimmune disease. Her diet is almost fat free to avoid pain and avoids bread which causes abdominal bloating along with her low sugar diet isn't too easy finding the right foods. She is waitng to go on a Dafne course which may help re educate her on her diet but this would not cover her current underlying condition. We enquired after a dietician but informed there was a long waiting list? She is a newly qualified nurse working a long way from home and is on 13hour shifts and I suspect she finds it difficult to manage her breaks and insulin during the shift although she was advised to register as disabled to ensure required breaks are taken? She is permanently tired and between shifts on her day off tries to rest as much as possible. We shall await the next series of blood test results and can only hope things are not getting worse as I often wonder how much more her body can actually tolerate? Her periods have been non-existant for 2 years and with all these things going on anyone who doesn't know her she looks a picture of health and just keeps going on without complaining - it's me thats the wreck!
Expert:  Anthony Bray, MD replied 3 years ago.

Hello again,

 

If she is a type one diabetic on insulin then she has to really watch her intake and insulin. She would be susceptible to both hyperglycemia and hypoglycemia. The diabetes may be related to her increased suspectibilty to infection.

 

Her diabetes is likely related to her fatigue as well.

 

I agree that her long shifts may adversely impact how well she may be able to manage her medication and diet.

 

If bread causes bloating then she might need to be tested for gluten sensitive enteropathy as well.

 

She should consult her gyn or endocrinologist with regard to her very irregular periods as well.

 

I hope this helps. Let me know if you have further questions. Best Regards,

 

Anthony Bray MD

Anthony Bray, MD, Doctor
Category: Health
Satisfied Customers: 6547
Experience: 14 years as clinician in the field of Family Practice
Anthony Bray, MD and other Health Specialists are ready to help you
Customer: replied 3 years ago.
Reference to my previous communications regarding fatigue due to long shifts, diabetes mellitus, non-alcoholic fatty liver disease, my daughter has now been prescribed statins through the GP. Her liver function tests have improved over the past 18months and from what was in the hundreds are now down to the 70s. Due to the statins my 24year old daughter has become totally incapacitated and has not been able to work due to severe muscle ache in her legs, back and shoulders and cannot seem to keep awake for very long. She rang the GP who advised her to stop taking the statins she had only been taking for 5 days and to go to hospital for some more liver function tests as it sounded a liver enzyme had been 'thrown out'. My daughter was not fit enough to get to pick the slip up from surgery and get to hospital until the following day when she had to get a taxi to get door to door. Three days later she is still tired and aching and says black circles have appeared under her eyes - her next earliest GP appointment is Friday 8th April. She lives on her own and I live 130 miles away and obviously quite concerned as to what is happenning. Are these current symptoms quite serious? She is more upset about not being able to get to work as a newly qualified nurse and her next 13hour shift is Monday. She tells me her bm's are ok although she's too tired to eat. I feel quite angry that the statins were introduced before the liver function tests were showing some normality and hasn't yet been referred to the liver specialist yet after the consultant gastroenterologist suggested would happen if the tests remained unstable.
Expert:  Anthony Bray, MD replied 3 years ago.

Hello!

 

The adverse affect with muscle pain /soreness/ or weakness occurs in less than 10% of those whom start on statins. It is the most common reason that this class of medication has to be stopped. In a small percentage it may even cause damage or breakdown of muscle tissue (rhabdomyolosis).

 

In some people it can cause a rise in liver function tests. This does tend to reduce the production and storage of fats>>cholesterol in the liver and so it may be of benefit with fatty liver disease.

 

With her experience I would recommend that she try a bile acid sequestrant which binds to fatty bile acids and increases the amount that is excreted through the GI tract. It reduces the amount of fat that is reabsorbed in the GI tract and in this way it tends to lessen the problem of fatty liver (over time...the effect is not immediate) This class of medication includes Welchol, Colestipol and Questran. This class is not subject to the same side effects as the statins and is not related to the statin group. Over time it should improve the fatty liver and improve the liver function tests back toward normal.

 

She wuld not be expected to have any muscle symptoms with this type of treatment. She should if she is prescribed one of these >> then she should take some vitamin supplements especially of vitamin A, D E and K as these are fat soluble vitamins and their absorption may be decreased by the bile acid sequestrant group.

 

 

I hope this information helps. If you have further questions then let me know and I will be happy to get back with you. Best Regards,

 

Anthony Bray MD

Anthony Bray, MD, Doctor
Category: Health
Satisfied Customers: 6547
Experience: 14 years as clinician in the field of Family Practice
Anthony Bray, MD and other Health Specialists are ready to help you
Customer: replied 3 years ago.
I think the statins were prescribed just based on the continual high cholesterol levels because it was explained to her that her body was ageing faster internally as a diabetic and that her arteries would be beginning to furr and would be prone to heart disease. The fact she doesn't have periods was explained that this part of her her body has automatically shut off as it cannot cope with anything else at the moment and not to worry. She is now being referred to a dietician due to her restricted diet and feeling tired especially with her low sugar, low fat diet although since been advised by the GP to start adding fat to the diet as she is exceptionally thin. As I mentioned earlier I think these statins were introduced prematurely and I appreciate your advice about the bile acid sequestrants.
Customer: replied 3 years ago.
My daughter is still aching and tired 4days after finishing the statins of which she only took for 5days. She is still not fit for work. I did read about Coenzyme Q10 being beneficial when statins are taken as this enzyme is affected by statins. She enquired with her GP and pharmicist and neither acknowleded this. I believe Q10 may boost the energy levels particularly in the energy production in the cells. The backs of her legs and shoulders are hurting and I was concerned about rhabdomyolysis although she only took the statins for a few days. I advised her to drink plenty of water to flush her kidneys and green tea to help detoxify her system. I am just a very concerned mother whose daughter should be enjoying life at 24years old. Am I giving her the right advice and how long could it take before she picks up?
Expert:  Anthony Bray, MD replied 3 years ago.

Hello again,

 

I agree with you on the CoQ10. I generally recommend 100mg/day of this if used as a supplement. The statins can deplete this nutrient but her short duration of taking the statin should not have had that much affect on this. Still CoQ10 is related to the cells conversion of sugar to energy. B-complex supplement may also have benefit to her fatigue.

 

The plenty of water is also sound advise in the event of rhabdomyolosis.

 

 

If she continues to have problems then she should have some follow up.

 

I hope this helps. Further questions are welcome if you have others. Best Regards,

 

Anthony Bray MD

Anthony Bray, MD, Doctor
Category: Health
Satisfied Customers: 6547
Experience: 14 years as clinician in the field of Family Practice
Anthony Bray, MD and other Health Specialists are ready to help you
Customer: replied 3 years ago.
I am glad you agree with my advice but still concerned why she is so tired and finding it hard to keep awake during the day and the bottom of her back is still hurting. She has a follow up appointment on Friday and work have been very understanding considering she hasn't been there too long. She has a study day Wednesday then a 13hour shift Thurs which I hope she gets through then off again for a couple of days. Lets hope she gets stronger by then. I am so angry the statins were introduced before her liver function tests were more normal I just feel we've gone back so many paces after struggling with the steatohepatitis diagnosis following the liver biopsy, the pain and the struggle of an almost fat free diet for the past 18months. I'll let you know how the follow up appointment goes on friday with the blood test results.
Expert:  Anthony Bray, MD replied 3 years ago.

Hello again,

 

Her fatigue and having trouble staying awake might be due to a separate problem. Fatigue is a common symptom to so many things but also within the symptom of fatigue there are often clues within the details. The sleepiness may reflect fatigue due to hypothyroidism or a sleep disorder (more commonly obstructive sleep apnea or restless leg syndrome) or certain other illnesses such as mononucleosis as some of the prime examples.

 

 

I think that rechecking her liver function tests and blood counts, muscle enzyme levels and perhaps full mono related titers(EBV ((Epstein Barr Virus>>titers and not simply a "monospot" test) may be of help. Inflammatory markers(C-reactive protein and sed rate)

may also be of some help.

 

I hope this helps some. I hope that she improves quickly. Best Regards,

 

Anthony Bray MD

Anthony Bray, MD, Doctor
Category: Health
Satisfied Customers: 6547
Experience: 14 years as clinician in the field of Family Practice
Anthony Bray, MD and other Health Specialists are ready to help you
Customer: replied 3 years ago.

A further liver function test had been carried out and she was told there were no significant changes detrimental to any previous readings but had more tests done whilst at the surgery which could be the muscle enzyme testing? Meanwhile an appointment has come through to attend an Endocrinology Clinic in May. Sorry I may seem vague with some of my details I am dealing with someone who is not always the most forthcoming talker and even monosyllabic on occasions. I try to phone her each day but the nagging mother doesn't always go down too well!

Expert:  Anthony Bray, MD replied 3 years ago.

Hi again,

 

I hope that her further evaluation goes well. Mainly I hope that she improves with regard to how she is doing overall. I'm glad to hear that follow up liver functions were apparently OK.

 

Take Care and Best Regards,

 

Anthony Bray MD

 

Anthony Bray, MD, Doctor
Category: Health
Satisfied Customers: 6547
Experience: 14 years as clinician in the field of Family Practice
Anthony Bray, MD and other Health Specialists are ready to help you
Customer: replied 3 years ago.

Reference to my daughter who was diagnosed with steatohepatitis has recently been in hospital with a severe kidney infection with hyperglycaemia and ketoacidosis and whilst during her stay a blood culture showed a growth of e-coli! She has been quite poorly and was severly dehydrated especially after a bout of severe diarrhoea the week previously. She is now back home and after a 10 course of antibiotics she is still feeling tired and not much appetite. After seeing the endocrinolgy specialist last month it was suggested she has glycogen storage disease. I am assuming this is not the same as steatohepatitis? I have tried reading up on GSD but not following it too well apart from realising it is to do with enzymes and synthesis? Are you able to explain it to me and is this why she is not 'picking up' very quickly?

Expert:  Anthony Bray, MD replied 3 years ago.

Hello!

 

You bring up a complicated class of disorder with glycogen storage disease. There are different subtypes of glycogen storage disease. Glycogen is a chained storage form of sugars.It may be associated with an enlarged liver with liver cells distended with glycogen and fat stored in structures called lipid vacuoles. It may be associated with high triglycerides, cholesterol and phospholipids. Low blood sugar and lactic acidosis would be a risk with certain types.

 

There are different enzymes which are the basic source of the problem in the different subtypes. Narrowing down the specific subtype will be necessary to completely classify her disease.

 

That is about all that I can tell you for now as I need to go offline for a while. I will be back later this afternoon.

 

The infection that she is recovering from may have much to do with her slow recovery but the glycogen storage disease may be a factor in this as well.

 

I will get back with you later this PM.

 

Take care for now! Anthony Bray MD

Anthony Bray, MD, Doctor
Category: Health
Satisfied Customers: 6547
Experience: 14 years as clinician in the field of Family Practice
Anthony Bray, MD and other Health Specialists are ready to help you
Customer: replied 3 years ago.

I became hopeful after the diagnosis of steatohepatitis learning that it was reversible over time especially helped by an appropriate diet. Now I'm not too sure whether the glycogen storage disease is reversible? Could it be hereditary? We could not trace a history of diabetes in the family but I do know my daughter's father had a mother that had a stroke at a fairly early age followed by several other strokes and spent many years in hospital. She became blind and paralysed. Unfortunately I have no contact with the fathers side of the family and it must be about 20years ago since his mother passed away. Although it would be difficult would it be worth trying to make some investigations? Understandably part of me doesn't want to know and live in hope my daughter can feel well and live a full life. She is taking herself on holiday next week and tells me she had started to take aspirin without consultation as she is concerned about the flying and blood clots after being on clexine every day whilst in hospital for 6 days. They mentioned her illness and condition had caused her blood to become 'glucky'? but since being discharged no further clexine was mentioned. She just ended up with antibiotics, codene for severe headaches which she doesn't normally have and antisickness tablets. Since finishing the antibiotics last Thursday she has no more headaches which I thought could have been due to the dehydration or antibiotics and the queeziness has also gone. Today she sounded much brighter considering she went back to work yesterday on a 13hour shift! As you will gather she is not easily defeated although has her moments of feeling down just through getting up each day and not feeling as well as she should. There are a few questions in this last response and hope you can give me some positive advice.

Expert:  Anthony Bray, MD replied 3 years ago.

Hello again!

 

There are different types of glycogen storage disease and some are inherited and others may be acquired.

 

The disorders may be subdivided into groups. One group involves muscle energy impairment.Another group involves mainly the liver and may be associated with enlarged liver and hypoglycemia as complications. A third group involves galactose disorders. A fourth group involves fructose disorders. (There are some overlap of some symptoms between groups such as hypoglycemia or enlargement of the liver within some of the groups other that the second)

 

 

I think that type Ia might be her disorder based on what we have discussed. This involves glucose -6 phosphatase deficiency (or translocase deficiency) This type may be associated with growth retardation, enlarged liver and kidney, hypoglycemia (this could be confused if she also had diabetes however), elevated blood lactate, high cholesterol and triglycerides and uric acid. She could be tested for G6PD (glucose 6 phosphatase deficiency) If she had this subtype then she would need some dietary restrictions and directions>> avoidance of fructose and galactose, dietary supplements of calcium and multivitamins. Hyperlipidemia would be likely treated with a cholesterol lowering medicine such as Lipitor or Crestor, Allopurinol might be needed to lower uric acid levels and reduce risk of gout. An ACE inhibitor (blood pressure medicine ) would be helpful to protect the kidneys and a citrate supplement might be needed to help protect against kidney stones. Note that a prolonged fast would need to be avoided as this would induce an acidosis.

 

The above example is relatively common as compared to some. There may be clues as to her subtype from any health problems during her childhood.

 

Other subtypes are possible and the type does need to be confirmed with testing. I don't suggest that you pursue any of the treatment steps for the above example without confirmation of the type with further testing. If she has G6PD deficiency then she would also need to let any MD know of the condition as there are some drugs that are contra-indicated with this condition.

 

Subtypes IX, 0 and XI would also potentially fit her clinical picture and these would be relatively benign in their course as compared to most of the others.

 

So I think that for now the theory that she may have a glycogen storage disease is just a theory but it does seem to fit with certain aspects of her findings. This theory needs to be confirmed and the subtype needs to be established if she indeed does have one of these. The potential treatment recommendations would vary depending on the subtype and specific enzyme deficiency.

 

Specifically pertinent to her situation of having diabetes plus a glycogen storage disease is the complicated picture that she may typically have high blood sugars but would be at high risk for abnormal LOW blood sugars if she fasted for a long period of time. (Glycogen is the buffer that is broken down into sugar when the supply runs low) This would also correspond to a lactic acidosis. These aspects would certainly fit. Some types of glycogen storage disease will have more or less effects on her liver, kidneys and muscles. She may have high cholesterol due to one of these glycogen storage diseases.

 

I hope this information helps. If you should have further questions then let me know and I will be happy to get back with you. If my answer has been helpful and to your satisfaction then please remember to press the "ACCEPT" button. Thank You and Best Regards,

 

Anthony Bray MD

 

Anthony Bray, MD, Doctor
Category: Health
Satisfied Customers: 6547
Experience: 14 years as clinician in the field of Family Practice
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