ALT liver function test | The London Clinic

The London Clinic through its Liver Centre provides access to the latest developments in the diagnosis and treatment of liver disease and performs private ALT Liver function tests.

Assessing liver health: ALT testing

ALT testing is a liver function test. It measures the level of alanine transaminase (ALT), an enzyme that is produced and used inside liver cells. If the liver is under stress, levels of ALT present in blood can start to rise. The test required involves taking only a tiny blood sample, and the results from The London Clinic’s diagnostics lab come back within hours.

ALT is an enzyme that is mostly produced by liver cells and therefore it is a good marker of liver disease. When ALT levels rise, it is usually a clear sign that the liver cells are showing signs of damage.

One of the biggest causes of raised ALT levels is fat in the liver, usually caused by drinking too much alcohol too frequently and/or eating a diet that is high in saturated fat. Raised ALT levels are an early sign of fatty liver disease. Viral hepatitis, side effects from prescription drugs and genetic or autoimmune conditions that affect the liver can also cause ALT levels to rise.

Why should I know my Serum ALT?

This is a simple and quick test and it can give a good indication if your liver is healthy, or it can indicate potential problems that need investigating further. The liver is unusual in that it can become extremely damaged without you noticing. Checking on your liver health with a simple ALT test can be life saving.

What does an ALT test involve?

A blood sample from a vein is required for the test. The blood is tested in the diagnostic laboratory at The London Clinic and the ALT level will be sent back to your consultant hepatologist, usually the same day.        

What causes ALT levels to rise?

• Fatty liver disease: perhaps the most common cause in the UK, Europe, the USA and other affluent countries is fat accumulation within liver cells. Fat can accumulate anywhere in the body, but when this happens in the liver cells, it proves toxic. Anyone who is obese, has type 2 diabetes, or a raised cholesterol level may be at risk for having fat within the liver. 
• Drinking too much alcohol: men who regularly drink more than the recommended 21 units of alcohol per week, women who drink in excess of 14 units per week, or people of both sexes who engage in regular binge drinking can risk damage to the liver cells.
• Infection by chronic hepatitis viruses such as viral infections transmitted through blood and bodily fluids such as hepatitis B and Hepatitis C
• Drug toxicity: even the common painkiller paracetamol can cause extensive liver damage when taken in quantities above the recommended dose. Other drugs can also have a toxic effect on the liver and your treatment will include regular monitoring of liver function.
• Haemochromatosis: a genetic liver disease associated with an excess accumulation of iron in the liver.
• Autoimmune hepatitis: this occurs when the body mounts an immune response to its own liver cells.

How often should I have my serum ALT measured?

If you are at particular risk of liver disease, either because of infection, underlying disease, or lifestyle factors, an ALT test done once a year could help monitor any changes in your liver health.

Treatment at The London Clinic

For more information about a private ALT Liver function test at The London Clinic complete the enquiry form or call the Liver Centre on +44 (0) 20 7616 7719.

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Medications and the Liver – American College of Gastroenterology

Overview

One of the main functions of the liver is to break down substances that we take by mouth, including medications, herbs and supplements. This process usually takes place efficiently and without causing any harm. When new medications are developed, they are extensively tested in many people prior to being approved for general use. During this period careful tests are done to ensure that the liver is not damaged. For this reason, the vast majority of the medications currently available are safe even for people with known liver disease.

Despite these safeguards sometimes medications can harm the liver. In some instances, a person can have a rare tendency that makes their liver susceptible to injury after taking a certain medication – we call this an idiosyncratic reaction. It happens in very rare instances and often cannot be predicted. Occasionally, medications that proved safe during testing are found to be potentially harmful when they are released for general use and millions of people take it. In other instances, people with liver disease may be at increased risk of developing liver damage when certain medications are used. Medications that are known to be toxic to people with liver disease usually carry a warning regarding its use in people with liver problems.

Symptoms

In most cases substantial liver damage can occur before symptoms appear. Typical symptoms of liver disease may include nausea, lack of appetite, discomfort on the right upper corner of the abdomen, generalized itching, dark urine and jaundice (yellow discoloration of the eyes and skin), but many people have no symptoms at all. Blood tests can usually detect evidence of liver damage before symptoms develop. When a medication known to possibly cause liver damage is used, your physician may recommend that blood tests be checked periodically after starting the medication so that any evidence of liver damage can be detected before symptoms appear.

Diagnosis

Liver damage of any type is usually detected by doing blood tests. Usually there is no need to monitor the liver tests when a medication is started. If your physician is planning on using a medication that in the past has been shown to rarely cause liver damage, the most common test used to monitor the liver is a liver panel, which consists of several blood tests that detect liver damage. These tests are: AST (aspartate aminotransferase), ALT (alanine aminotransferase), AP (alkaline phosphatase) and bilirubin. There are many other causes for elevated liver tests. For that reason your physician may obtain a baseline liver panel prior to starting a medication to be sure that it is normal.

Minor elevations of these tests may occur after starting a medication and do not indicate significant liver damage. Generally speaking physicians are most concerned about serious medication-induced liver damage when the levels of AST and ALT rise 3 to 5 times or more over baseline or if there is an increase in bilirubin. If the elevations are minor, the medication is continued and the liver tests monitored. In most cases, the liver tests will return to normal despite continuing the medication.

Common Medications That Can Cause Liver Damage

The best known medication that can damage the liver is acetaminophen, also known as Tylenol®. This medication is widely available without prescription and is present in many of the cold and flu remedies sold in drugstores as well as in prescription pain medications.  Most pain medications that are labeled as “non-aspirin” have acetaminophen as its main ingredient.

Acetaminophen, when used as directed, is extremely safe even for people with liver disease. However, taking too much acetaminophen at once, or taking a high dose of acetaminophen continuously over several days can cause damage to the liver. Healthy individuals should not take more than 1,000 mg of acetaminophen per dose, and should not take more than 4,000mg in one day (i.e. maximum of 1,000 mg every 8 hours). In addition, even healthy persons should avoid taking 3,000mg of acetaminophen daily for more than 3 to 5 days. Patients with liver disease should restrict the daily amount of acetaminophen to 2,000mg per day, or even less if severe liver disease is present. Even if you have no liver disease, always use the smallest amount of acetaminophen needed to obtain relief. It is important that you read the labels of all prescription and non-prescription medications that you take. Often acetaminophen may be present in several medications which could cause you to take a dose of acetaminophen that exceeds the safe limits.

People who drink alcoholic beverages regularly are at higher risk of developing severe liver damage from acetaminophen. Drinking alcohol regularly changes the way the liver breaks down certain medications. In the case of acetaminophen, alcohol use leads to accumulation in the liver of a toxic byproduct of acetaminophen that can kill the liver cells. People who drink alcohol regularly should not take acetaminophen or take it in small doses if at all.

Cholesterol Lowering Medications

Another common group of medications that can affect the liver tests are the cholesterol lowering medications commonly known as “statins”; a group that includes many of the currently prescribed medications to lower cholesterol. These medications have been used in millions of people with an excellent safety record and very little evidence of liver damage, even when used in people with mild liver disease. It is not rare, however, for people to develop minor elevations of the liver tests soon after they start taking these medications. In the vast majority of cases, these elevations are less than 3 times the baseline level and the levels return to normal despite continued use of the medication; recently the FDA discontinued the recommendation for routine monitoring of liver tests when starting a patient on statins. If the liver tests are monitored, the medication should not be stopped if only minor elevations of liver tests are noted.

Supplements and Herbs

Supplements and herbs, despite being “natural” can be toxic to the liver. The production and distribution of these supplements is not regulated as carefully as the production of prescription medications. “Natural” products can be sold with little testing and with no proof of efficacy. Sometimes the herb or supplement itself can cause liver damage. In other cases, impurities or toxins introduced during the preparation of the product may be toxic to the liver. Some of the natural products known to be toxic to the liver include chaparral, comfrey tea, kava, skullcap, and yohimbe, but there are many others. Even vitamin supplements and dietary supplements, such as weight losing products, can be harmful. Too much iron or vitamin A can result in significant liver damage. Generally speaking, you do not need to take iron supplements unless you have been diagnosed with iron deficiency. Vitamin A dose should never exceed 5,000 units a day, unless provided as beta-carotene.

Medication Use in People with Liver Disease

With very rare exceptions, people that have mild liver disease can safely take most common prescription and non-prescription medications at the recommended dose. Having mild liver disease such as hepatitis C or fatty liver does not increase the risk that a given medication will be toxic to the liver, however, if a person with pre-existing liver disease happens to develop liver injury from a medication, the resulting liver damage may be more severe than would occur in an otherwise healthy person with the same reaction. For that reason, whenever possible, physicians prefer to use “liver-safe” medications when we know a person has liver disease.

Often physicians may be reluctant to start patients on a cholesterol lowering medication if the liver tests are already mildly elevated; usually due to fatty liver disease. Research has shown that cholesterol lowering medications are safe in people with fatty liver disease or mild hepatitis C infection, and in fact, may be beneficial to the liver by decreasing inflammation.

People with more severe types of liver disease such as cirrhosis have to be more careful regarding the types and dose of medications they take. While the ability of the liver to properly break down and utilize medications is preserved even when severe liver disease is present, there are some medications that should not be used or should be used at reduced dose when given to patients with advanced cirrhosis.

Recommendations to Minimize the Risk of Liver Injury from Medications

1. Always keep a list of all the prescription and non-prescription medications that you take, including herbs, vitamins and supplements. Bring this list with you to every physician’s appointment.
2. The fewer medications you take the better. This includes herbs, supplements, prescription and non-prescription medications. If you have several physicians prescribing medications for you, be sure all of them are updated on your current list of medications.
3. When using non-prescription medications, be sure to read the label carefully and never exceed the recommended amount. Avoid taking the maximum recommended dose for a prolonged period without consulting a physician.
4. If you are taking several medications, be sure the ingredients are not the same; otherwise you may risk taking an accidental overdose.
5. If you drink a significant amount of alcohol daily, avoid or restrict the use of acetaminophen; never take the maximum recommended dose.
6. If you have liver disease, make sure that your physician is aware of your diagnosis and the severity of your liver disease.
7. If you have advanced liver disease such as severe cirrhosis, it is a good idea to consult with the liver specialist before starting new medications.

Author(s) and Publication Date(s)

Jorge L. Herrera, MD, FACG, University of South Alabama College of Medicine, Mobile, AL – Published November 2007. Updated December 2012.

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Why Too Many Patients Get Liver Tests They Don’t Need

It can start with the quick check of a box: A doctor orders a range of blood tests all at once, hoping to figure out what’s causing a patient to show signs of liver damage.

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It sounds harmless enough, not to mention quicker and more convenient than making the patient come back for more blood tests later.

But ordering too many liver tests at once may lead to unneeded worry, biopsies and costs, says a University of Michigan researcher who has studied the issue from many angles.

He and colleagues examine the issue of “over-testing” for liver conditions in two new papers published in the Journal of Hospital Medicine and the Journal of Hepatology. The new papers focus, respectively, on the 1 to 2 percent of all hospital patients who show very high levels of liver enzymes, and the 8 percent of clinic patients who have slightly high levels.

Both papers recommend that doctors should rule out common liver issues before testing for the uncommon ones. They also say that the modern computer systems doctors use to order liver tests should help them pause and make wiser choices.

It isn’t the initial $100 blood test for elevated liver enzymes that concerns Elliot Tapper, M.D., M.S. It’s the trend toward “one-stop shopping” testing, often ordered with the single click of a checkbox on a computer screen, that proceeds it.

“Physicians are legitimately thinking they’re doing the right thing by ordering the full panel of tests, being thorough and trying not to miss anything. In the hospital, they may be doing what a consulting liver specialist has suggested,” says Tapper, a gastroenterologist who treats liver diseases and conducts data-driven research on them at the U-M Institute for Healthcare Policy and Innovation.

“But they’re not aware of, or thinking about, the ramifications,” he continues. “This can include false positives for rare diseases that can cause the patient and their family anxiety and lead to unnecessary liver biopsies.”

New Recommendations Call for Standard ALT Screenings

From the American Association for the Study of Liver DiseasesAlarming Evidence Shows Elevated ALT Ups Mortality by 60%

BOSTON—Knowing your alanine aminotransferase (ALT) level, like knowing your blood pressure, fasting blood glucose, hemoglobin A1c, and cholesterol levels, should become part of basic personal health awareness, according to new recommendations from the American Association for the Study of Liver Diseases (AASLD) that were presented at the association’s annual meeting.

ALT, a protein made predominantly in the liver, participates in the modification of amino acids. Mounting evidence from population-based studies has documented a strong association between elevated ALT levels and subsequent mortality. Mortality rates jump by 60% to 80% when ALT goes beyond twice the upper limit of normal, with the risk further magnified among women.

Adrian M. Di Bisceglie, MD, chief of hepatology, Saint. Louis University School of Medicine, and chairman of public policy for the AASLD, said at the meeting that abnormal ALT activity is often ignored or minimized by physicians who construe them to be clinically insignificant in asymptomatic patients. “Every raised ALT is worthy of examination,” he stated, “especially when it persists over 3 to 6 months.”

The American Liver Foundation estimates that 30 million Americans, knowingly or not, have liver disease. With the epidemic rise in the prevalence of obesity and metabolic syndromes, the most common cause of ALT elevations in North America is fat accumulation within liver cells, known as non-alcoholic fatty liver disease (NAFLD). Fat accumulations in the liver are toxic. Other causes of ALT elevations include excessive alcohol consumption, chronic hepatitis virus infection, drug toxicity, and genetic and autoimmune liver diseases.

“Also of great concern is a new message emerging over the last 3 to 4 years that the mortality risk is raised with elevated ALT, not only in liver disease but also in non—liver-related ailments, particularly cardiovascular disease,” Dr Di Bisceglie said. “A persistently raised ALT is a symptom that one’s body is sick, usually because one is overweight or on the way to diabetes.”

Dr Di Bisceglie estimated that in any group of 100 patients with raised ALT levels, about:

• 30-40 would have NAFLD

• 10-20 would have hepatitis

• 5-10 would have alcohol-related increases

• 5 would have bile duct disorders

• 5 would have autoimmune liver diseases.

Finally, in about 15 to 20 patients, raised ALT would be related to drugs and medicines. The etiology is unknown in others.

Among the drugs most likely to cause acute liver injury, acetaminophen can be the most dangerous, because of its toxicity at relatively low doses, especially in those with high alcohol consumption. This drug and others with liver-harming potential (eg, anticonvulsants, antibiotics, and statins) account for 80% of drug-related liver toxicities.

What then is an elevated ALT level? The lack of standardization among laboratories, Dr Di Bisceglie conceded, is part of the problem. Different labs can define anywhere from 40 to 65 U/L as normal. “Unfortunately,” he said, “their samplings conducted to determine what is normal can include high proportions of overweight patients with a bit of fatty liver disease that push the normal range up. That’s why we need an effort to create a national standard. ” A level of 60 U/L should be considered mildly ele-vated, he says.

The new recommendations call for making ALT a standard screening metric and requiring further investigation when abnormal levels are detected. “It is not a fancy test, but simply part of the standard multiphasic panels included with the blood test,” he noted.

The important point is that many liver diseases can be treated when they are caught early. “We don’t want physicians to ignore ALT elevations, because they very often are a flag for potentially serious liver disease,” Dr Di Bisceglie emphasized.

How I Lowered my ALT Levels Below 20

Sugar, or sucrose if you want to get fancy, is comprised of both glucose and fructose at the molecular level. And although sugar is delicious, and fun to pass out at Halloween to the neighbor kids, it’s like a torpedo aimed right at your liver, arguably the body’s most important organ after the heart. .

While glucose, which is the energy we derive from carbohydrates, can be used by every cell in the body for energy, fructose, is only metabolized in the liver.

In fact, the more sugar we eat, the harder it is on the liver, which is why cases of non-alcoholic fatty liver disease (“NAFLD”) in children eating high sugar diets are on the rise.

Of course, fructose isn’t all bad.

Sugar rich sports drinks like Gatorade can replenish glycogen in the liver after extreme athletic events. ¹ For example, when you run a marathon, the body relies on all of its stored “carbohydrate fuel,” known as glycogen, to power your muscles. When you’re truly depleted after the race, sending sugar into the liver can be a positive thing. However, for most of us most of the time, sugar is like a torpedo to the liver which causes the storage of fat rather than the glycogen we need for a big day of activity.

One way to estimate liver health is to measure for an enzyme produced by the liver when it’s under stress known as alanine aminotransferase or “ALT. ”

When the liver is damaged, it releases more ALT as a cry for help.

Alongside uric acid, ALT is often viewed as a sign of fructose toxicity in the liver.

What are healthy ALT levels?

According to the lab I used to measure my ALT levels, Boston Heart Diagnostics, healthy ALT levels are <40 U/L and the borderline range extends all the way to 120 U/L.

However, in light of new studies associating ALT of over 31 U/L for men and 23 U/L for women with insulin resistance and metabolic syndrome, it seems the targets for ALT should move lower. ²

Causes of high ALT levels

The Mayo Clinic lists some of the most common causes of elevated ALT. Their short list includes:

• Obesity
• NAFLD
• Tylenol and over the counter medication
• Hepatitis
• Statins
• Drinking too much alcohol

Can diet increase ALT?

Taking a glance at the Mayo Clinic list of ALT causes, it would appear the answer is a resounding yes.

We know that NAFLD is on the rise because of sugar in the diet. Alcohol is a dietary factor and we also know that diet can play a role in obesity.

I made some dietary changes aimed at improving my liver health and recorded the results for this blog.

How I lowered my ALT levels

My normal ALT levels have historically been on the upper end of the healthy range, with an average number sitting around 26 U/L.

However, I have also seen elevated ALT.

Reviewing past labs, I had an outlier number of 48 U/L in September of 2018 (racking my brain as I write this to remember what was going on in September of 2018 which gave me such high ALT levels). One explanation could be strenuous exercise and a subsequent poorly timed blood test, which has been shown to transiently elevate ALT in some healthy people. ³

Unfortunately, I haven’t had ALT measured as frequently as my lipid panels, but I do have some historical data to share below.

Previous ALT lab results:

• 9/30/15 – 16 U/L
• 7/29/16 – 33 U/L
• 2/23/17 – 29 U/L
• 11/1/17 – 26 U/L
• 9/9/18 – 48 U/L
• 4/5/19 – 41 U/L
• 3/17/20 – 20 U/L

The ALT lab value of 41 U/L you see in April of last year came after I did my infamous pizza and mezcal blood draw, so that higher number is easily explained.

The latest value of 20 U/L is interesting to me for two reasons:

1. It came after I gave up sugar for 40 days during Lent;
2. I also gave up coffee for Lent and;
3. I didn’t go low carb

Why is this interesting?

Giving up sugar lowered my ALT

Although there are a number of things that can cause ALT to spike, including liver disease and alcohol abuse, many physicians believe ALT is a marker of fructose induced damage to the liver.

As such, it wasn’t a huge shock that my ALT levels fell to a 5 year low by simply removing sugar from my diet.

Strenuous exercise at high altitude

My insulin resistance lab results have always been excellent, but during the period that this blood draw reported on, specifically Lent, I focused on staying as insulin sensitive as possible.

Not only did I exclude all sugar, I exercised with strenuous skiing at high altitude in Jackson Hole, and when I got back to my home gym, made sure to lift heavy weights to move glycogen out of my muscles.

Insulin resistance is associated with high ALT, and studies show low sugar diets reliably bring ALT levels down. ⁴

Coffee wasn’t keeping my ALT levels low

Regular readers of this blog will know that I have a complicated relationship with coffee. And while we can debate the pros and cons of a morning cup of Joe, one of the commonly cited coffee benefits is promoting liver health.

Every single listacle on the internet discussing ALT will tell you – drink coffee to lower ALT!

In fact, these claims are backed up by a family of studies which show coffee drinkers, of both caffeinated coffee and decaffeinated coffee, tend to have lower levels of ALT. ⁵⁶

Perhaps had I added my usual cup of coffee to my sugar free diet my ALT would have gone even lower, but I was able to achieve some of my best ALT levels without any coffee at all.

Low carb diets and ALT

Studies are mixed on this issue, but a recent meta-analysis showed reduced liver fat content in patients with NAFLD, but no significant reduction in ALT and other liver enzymes when following a low carbohydrate diet (defined by the American Diabetes Association as between 26-45% of total calories from carbohydrate).

In my case, fruit in the form of apples and bananas, as well as potatoes, rice, beans and other complex carbohydrates remained on my menu for the duration of this experiment. I was still able to achieve a healthy ALT level even with the fructose in fruit.

Ketogenic diets and ALT

Is is important to note that some people following a ketogenic diet will see elevated liver enzymes as well, so the Gene Food message of personalized nutrition applies to this conversation as usual. ⁷ Consider this case study in which a woman saw ALT go from 18 U/L to 119 U/L after going keto. The ALT values returned to 25 U/L eight months after ending keto. The lesson here is that a lower carb diet is not a zero carb diet and going zero carb, say carnivore for example, could have a deleterious effect on ALT levels.

Key Takeaways

1. Elevated ALT levels can be a sign of too much sugar
2. Coffee could lower ALT, but in many people the results will be modest
3. Sugar free diets may help improve liver health
4. Low carbohydrate diets can lower fat in the liver in some people, but taking it too far and going full ketogenic may actually contribute to NAFLD and elevated ALT

AST/ALT

AST/ALT

Alanine aminotransferase
(ALT) and Aspartate aminotransferase (AST)

Alanine aminotranferease (ALT) and aspartate
aminotransferase (AST) are enzymes located in liver cells that
leak out into the general circulation when liver cells are
injured. These two enzymes were previously known as the SGPT
(serum glutamic-pyruvic transaminase) and the SGOT (serum
glutaic-oxaloacetic transaminase). These two transaminase enzymes
may be reported on lab slips with both their new names and
previous names or by their newer names only. ALT and AST are
present in highest concentrations in cells from the liver, heart,
skeletal muscles, and red blood cells. Patients whose LFTs show a
predominant rise in the transaminases have liver diseases that
are characterized by hepatocellular damage.

ALT is found predominately in the liver, with
lesser quantities found in the kidneys, heart, and skeletal
muscle. As a result, the ALT is a more specific indicator of
liver inflammation than the AST, as the AST may also be elevated
in diseases affecting other organs, such as the heart or muscles.
The AST is also elevated after a myocardial infarction, and
during acute pancreatitis, acute hemolytic anemia, severe burns,
acute renal disease, musculoskeletal diseases, and trauma.
Because intramuscular (IM) injections cause muscle trauma that
may release AST and ALT into the bloodstream, IM injections
should be avoided before LFTs are done. If an IM injection must
be given close to the time blood for LFTs is drawn, the nurse
should indicate on the lab slip the time the injection is given.
Many liver enzyme tests are also affected by medications. It is
important to consult the laboratory manual for medications that
should be considered in the interpretation of test results, and
to indicate such medications on the lab slip.

Instant Feedback:

ALT is a
more specific indicator of liver inflammation than the AST.

TRUE or FALSE

In acute liver injury, such as viral hepatitis,
the ALT and AST may be as high as 1000U/L. In chronic hepatitis
or cirrhosis of the liver, ALT and AST may be 10 to 100 times
their normal values.

Laboratory Studies, Imaging Studies, Histologic Findings

Author

Michael J Barsoom, MD, FACOG Director, Division of Maternal-Fetal Medicine, Alegent Health at Bergan Mercy Medical Center

Michael J Barsoom, MD, FACOG is a member of the following medical societies: American College of Obstetricians and Gynecologists, American Institute of Ultrasound in Medicine, Society for Maternal-Fetal Medicine

Disclosure: Nothing to disclose.

Coauthor(s)

Brent J Tierney, MD Resident Physician, Department of Obstetrics and Gynecology, Creighton University Medical Center

Brent J Tierney, MD is a member of the following medical societies: American College of Obstetricians and Gynecologists, American Medical Association, Nebraska Medical Association

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Chief Editor

Ronald M Ramus, MD Professor of Obstetrics and Gynecology, Director, Division of Maternal-Fetal Medicine, Virginia Commonwealth University School of Medicine

Ronald M Ramus, MD is a member of the following medical societies: American College of Obstetricians and Gynecologists, American Institute of Ultrasound in Medicine, Medical Society of Virginia, Society for Maternal-Fetal Medicine

Disclosure: Nothing to disclose.

Additional Contributors

Suzanne R Trupin, MD, FACOG Clinical Professor, Department of Obstetrics and Gynecology, University of Illinois College of Medicine at Urbana-Champaign; CEO and Owner, Women’s Health Practice; CEO and Owner, Hada Cosmetic Medicine and Midwest Surgical Center

Suzanne R Trupin, MD, FACOG is a member of the following medical societies: American College of Obstetricians and Gynecologists, American Institute of Ultrasound in Medicine, International Society for Clinical Densitometry, AAGL, North American Menopause Society, American Medical Association, Association of Reproductive Health Professionals

Disclosure: Nothing to disclose.

90,000 Stages of Liver Disease – American Liver Foundation

To live, we all need a healthy liver – it is so important that “

live ” In the title!

Where to Find Your Liver
The liver is the largest internal organ in your body, weighing between 3 and 5 pounds. The liver is located on the right side of the upper body, below the lungs, taking up most of the space in the chest. The gallbladder, which stores the bile produced in the liver, is located under your liver.Your liver is made up of two separate parts, or lobes: the larger right lobe and the smaller left lobe. The two lobes are separated by tissue that holds your liver in place.

What Your Liver Does
Your liver’s greatest role is to filter your blood all day, every day. A healthy liver takes on a deep reddish brown color because it is soaked in blood. At any given moment, your liver contains about half a liter of blood, or 13% of your total blood supply. Your liver filters more than a liter of blood every minute, which is about 22 gallons of blood per hour and more than 250 gallons of blood in 24 hours. There are two sources that supply your liver with all this blood: hepatic artery and horizontal distribution portal vein . The hepatic artery delivers oxygen-rich blood to the liver. Blood from your digestive system travels to the liver through the hepatic portal vein with nutrients, drugs, or toxins.

Parts of your liver
As mentioned earlier, the liver has two lobes. Each lobe is made up of smaller sections called lobules which are collections of liver cells. The portal vein and hepatic artery enter the liver, sending one large trunk to the left lobe and one large trunk to the right lobe, gradually dividing into smaller branches, creating a network of vessels through which blood flows to each lobe. Once the cells in the lobule process blood, ducts (small tubes) transport bile out of the cell, while filtered blood flows into the veins in the center of each lobule. Veins emerge from the lobules, passing into larger veins, eventually passing into the hepatic veins; then the blood leaves the liver through the inferior vena cava , the largest vein in the body. The ducts transport bile from the lobule to the larger right and left hepatic ducts. These two large ducts join to form the common hepatic duct. In , the common hepatic duct drains bile into gallbladder where it is stored and brings bile into the first part of the small intestine.

How your liver works
Unlike the lungs or the heart, we do not feel how our liver is working. Many people don’t think about their liver until something is wrong with it. Your liver is an incredibly hardworking organ with over 500 different vital functions. Only your brain has more functions than your liver. Many liver functions are linked to your metabolism . These metabolic functions allow you to convert food into energy, break down food into the basic building blocks your body needs, and eliminate waste.

Liver …

• Produces bile
  • Bile is a yellow-green acidic liquid that helps to eliminate waste and break down fats in the small intestine during digestion.
• Produces proteins for blood plasma
  • Blood plasma is the fluid that carries blood components (red and white blood cells and platelets), nutrients, hormones, proteins and waste products.
• Produces cholesterol and special proteins that help transport fat through the body
• Converts unused glucose to glycogen for storage
  • If needed, glycogen can be converted back to glucose for energy.
  • Balances blood sugar and produces glucose as needed
• Regulates the levels of amino acid in the blood
  • Amino acids form the building blocks of proteins.
• Stores iron processed hemoglobin
  • Hemoglobin is an oxygen-carrying protein in red blood cells.
• Converts toxic ammonia from digestion to urea.
• Converts drugs and other poisonous substances into your body
• Regulates blood clotting (or our ability to stop bleeding)
• Fights infections by building up immune factors and removing bacteria from the bloodstream.
• Removes bilirubin from red blood cells

The liver often removes harmful substances from our body by breaking them down into smaller by-products. These byproducts leave the liver in bile or blood – bile byproducts are removed from the body through feces, and those in the blood are filtered out by the kidneys and excreted in urine.

90,000 What tests show liver cancer

About the disease

As a rule, the precursors of liver cancer are chronic organ diseases:

• Hepatitis;
• Cirrhosis;
• Hepatosis;
• Invasions of a parasitic nature.

The listed precancerous diseases contribute to pathological changes in the liver:

• Increased bilirubin;
• Increased hepatic transaminase;
• The manifestation of “sign” symptoms, for example, chronic weakness, fatigue, heaviness in the localization of the liver, jaundice, etc.d.

It is important for people at risk to periodically undergo dispensary examinations, take appropriate tests, participate in diagnostic activities in order to early detect a malignant tumor.

You need to know that the initial stage of liver cancer is often asymptomatic or simply invisible against the background of precancerous diseases.

Symptoms are found already at 2-3 stages:

• Rapid weight loss;
• Severity in the area of ​​the right hypochondrium and pain syndrome;
• Enlarged liver size;
• Jaundice;
• Ascites.

In addition, biochemical analyzes show a sharp increase in liver enzymes and bilirubin.

Tumor markers

Tumor markers are unique chemicals found in patients with cancer in the blood and urine. Once upon a time, tumor markers were considered the main means of early diagnosis of cancer, but now it has become clear that this is not the case.

Practical experience with the use of tumor markers has shown that their presence and increase may be the result not of cancer, but of other pathologies.Conversely, they showed a negative result in cases of diagnosis of oncology.

Today, tumor markers are used in the initial examination. In most cases, such an analysis is secondary, this is an additional diagnosis, which subsequently helps to monitor treatment, predict relapses, and the development of the disease.

Tumor markers and liver oncology

The main tumor marker in initial liver cancer is alpha-fetoprotein (AFP).This protein plays a dominant role in the period of intrauterine development of the fetus. Initially, it is produced by the corpus luteum, which produces the woman’s ovaries, then synthesizes this protein in the liver and in the digestive system.

AFP is responsible for the transport of fatty acids to the fetus, suppresses the immune reactions that would inevitably arise in him as a reaction to the synthesis of new antigens.

Studies have shown that AFP increased in 70-95% of patients with liver cancer at the initial stage, and at the latter – by only 9-10%.

In case of liver oncology, it is possible to search for other tumor markers that are less typical for this disease. This is:

• Embryonic cancer antigen (CEA). Its sharp increase is observed in cancers of the digestive system, less often in liver pathology. An increase in CEA is characteristic of smokers, as well as people with chronic inflammatory intestinal diseases.
• CA 19-9. The digestive system produces this protein.Sometimes it is important for determining a tumor of the pancreas, less often – chronic pathologies of the liver and its primary tumor.
• Ferritin. This protein is a marker of inflammation, as well as a number of cancers, including liver tumors.

Readings

The analysis is shown for patients who are at risk for the development of primary oncology:

• Suffering from chronic hepatitis, cirrhosis and some other diseases that increase the risk of liver cancer;
• The presence of a different type of oncology, if there is a suspicion of metastases in the organ.
• In the diagnosis of the primary form of liver oncology in order to monitor the effectiveness of therapy, the development of the disease, the occurrence of its relapses.
• During the initial examination procedure in pregnant women and some poorly differentiated tumors.

The material for analysis is venous blood, which is taken on an empty stomach. 30 minutes before donating blood, the patient should not smoke and experience high physical activity.

Analysis transcript

When decoding the analysis for tumor markers, the clinical situation and data from other examinations are taken into account. For an accurate assessment, additional information is important.

Normal test values ​​are as follows:

AFP – <7.9 IU / ml.

CEA – <5.5 ng / ml. - for smokers, <3.8 ng / ml. - for non-smokers.

CA 19-9 below 34 U / ml.

Ferritin 20-250 mcg / l – for men, 10-120 mcg / l – for women.

If the tumor marker has increased, further actions should take into account the clinical situation in a particular patient.

A decrease in the AFP level indicates the effectiveness of the treatment of liver tumors. Its increase after a certain period of time signals the presence of a relapse.

Elevated but stable AFP is the result of non-radical treatment.

An increase in the AFP level is a sign of the progression of the process and the need to revise treatment tactics.

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90,000 Liver cancer – Docrates

Among men, cases of liver cancer are twice as common as among women, due to the difference in alcohol consumption. One of the most common types of liver cancer is liver cell cancer (primary cancer), in the language of medicine called hepatocellular carcinoma (abbreviation HCC). In turn, a tumor originating from the biliary tract, cancer of the biliary tract (cholangiocarcinoma), is less common. What these cancers have in common is that they most often occur in the liver as a consequence of cirrhosis or chronic biliary tract disease. In medicine, biliary tract cancer can also be classified as a type of gallbladder cancer.

Hepatocellular carcinoma can metastasize to other parts of the liver, although not as often as other types of cancer, and is diagnosed at a later stage, when metastases have penetrated, for example, bone tissue or lungs. Often, in the early stages, the tumor grows and progresses very slowly. Advanced liver cancer can cause internal bleeding, ascites, or liver failure.

Risk factors for liver cancer

Cirrhosis and other liver diseases are the leading cause of liver cancer in Western countries. According to the majority of experts in the world, it is most often caused by chronic liver inflammation caused by the hepatitis B virus. In African and Asian countries, hepatitis B and C are very common and, as a result, cirrhosis and liver cancer are quite common there. Alcohol abuse is the most common cause of cirrhosis in Finland and other Western countries. However, rare liver diseases that have nothing to do with alcohol consumption can also cause liver cancer.In Western countries, a growing health threat is being overweight, which leads to excessive accumulation of fat in the liver and metabolic syndrome, which increase the risk of cancer. This problem is especially acute in the United States, but is gaining momentum in other countries.

In addition, a disease such as hemochromatosis also causes cirrhosis and liver cancer. Hemochromatosis is a violation of iron metabolism, due to which excess iron accumulates in the liver, pancreas and other organs.If this disease is left untreated, the risk of primary liver cancer increases by about 200 times. However, if the problem is eliminated in time, before cirrhosis of the liver has developed, then the risk of getting cancer is reduced to nothing.

Other risk factors include diabetes, old age and smoking.

Liver cancer symptoms

In most cases, primary liver cancer is asymptomatic, which is why the correct diagnosis is delayed. Most often, signs of the disease appear already when the tumor has spread outside the liver or metastasized to other organs.Symptoms of primary cancer are common symptoms that can be associated with various ailments, and people do not always think about the fact that it can be cancer.

Fatigue, a feeling of heaviness in the upper abdomen and loss of appetite can signal the presence of a malignant neoplasm. If the swelling is painful and is felt in the upper abdomen, it may already have grown to a fairly large size. Secondary symptoms of liver cancer include weight loss, sometimes fever, vomiting, and yellow skin.The latter occurs because the liver is no longer able to remove bilirubin from the blood. Itching can also be a sign of liver cancer due to changes in bile acid levels in the blood.

Diagnosis of liver cancer

If liver cancer is suspected, blood tests and liver counts are usually taken first. Almost always, a blood test can be used to determine whether a person has liver cancer or not.

Using computed tomography (CT) and magnetic resonance imaging (MRI), accurate images are obtained, which greatly simplifies the diagnosis.Computed tomography allows you to see if the tumor has spread to nearby tissues or blood vessels. During a diagnostic study, a sample of tumor tissue is taken (biopsy). This is necessary in order to determine whether the patient has cancer or not. A biopsy is the only way to determine if a liver mass is benign or malignant. If the presence of a malignant tumor is confirmed, then the degree of its prevalence is determined.

If liver cancer is suspected, laboratory tests are also carried out.A blood test is taken for alpha-fetoprotein AFP (liver tumor marker), the level of which is increased in 80% of patients with primary liver cancer. If the AFP level increases over time, then this is a clear indicator of the presence of cancer. When choosing methods for the treatment of liver cancer, blood tests are also taken to examine the abnormalities in its work, which are often a consequence of a disease that precedes the cancer.

Liver cancer treatment

Treatment of liver cancer is planned in each case individually, depending on the extent of the tumor, how the liver works, and the general condition of the patient.The choice of the type of treatment is also influenced by the possible concomitant diseases and the medications taken. The main criterion for whether surgery can be performed is the localization of the tumor in relation to the main vascular systems and structures of the biliary tract, as well as the size and number of malignant neoplasms.

Treatment may consist of one or more of the following methods:

Surgical intervention is the only treatment with a chance of recovery.However, in this case, the tumor must be resectable, i. e. small in size and is located in the section of the liver, from where it can be removed. In addition, the organ must be relatively healthy. Often, at the time of cancer diagnosis, the liver is already in a rather poor condition due to cirrhosis, and therefore, surgical intervention is possible in extremely rare cases.

Approximately one quarter of all organ tissue can be safely removed during surgery. However, this is possible if liver failure is not too severe.Provided the liver is generally healthy, up to 70-80% of the tissue can be removed. If the liver is damaged, but the size of the tumors is small and the number is from 1 to 3, liver transplantation can give good results.

If surgery is not possible, other methods of treatment can reduce the tumor or slow its growth. In the presence of one or only a few tumors, in some cases it is possible to resort to a method of local exposure, for example, radiofrequency thermoablation. During this procedure, a needle electrode is inserted directly into the tumor, which transmits radio frequency radiation and heats the tumor for a short time to a high temperature, thereby destroying cancer and healthy cells.

During chemoembolization (TACE method), the drug is injected directly into the artery that supplies the tumor with blood. At the same time, the veins feeding the tumor are examined with an embolizing agent. Sometimes, in quite rare cases, the TACE technique is so effective that the tumor is reduced to a size that allows surgery to remove it. In some cases, selective interstitial radiation therapy (SIRT) is used, the essence of which is that microscopic particles are injected into the artery, which create high-level local internal radiation in the blood vessels of the tumor.

External radiation therapy is used mainly when the spread of the tumor causes pain in the patient. The use of radiation therapy is limited by the fact that healthy liver tissue is very sensitive to this type of exposure.

The only known drug therapy that prolongs the patient’s life is treatment with the targeted antineoplastic agent Sorafenib. It is prescribed in cases where the cancer is already very widespread and does not respond to local treatment (surgery, radiofrequency thermoablation or embolization). Today, new drug methods are being investigated.

Successful treatment of primary liver cancer requires well-coordinated work of oncological surgeons and specialists in chemotherapy and radiation therapy. In Finland, the surgical treatment of liver diseases is at the highest level. In order to choose the right treatment, the Docrates clinic specialists pay special attention to the accurate diagnosis of primary liver cancer at an early stage. Treatment of advanced cancer is carried out here by specialists of the highest level with many years of experience in this area.

90,000 What damages the liver?

Let us briefly describe the main factors that damage the liver.

Viruses.

Infection with viruses A and E occurs through the fecal-oral route, that is, through water, food, children’s toys. The hepatitis A virus is ubiquitous, while E is predominantly found in Southeast and Central Asia. These hepatitis occur only in an acute form and usually end in full recovery. The situation is different with viruses B, C and D.They are transmitted through blood, less often sexually and from mother to child, as well as through intravenous drug administration. Omitting unnecessary details, it should be noted that these pathogens can, albeit with different frequencies, cause chronic liver damage. In this case, the viruses themselves either do not possess at all, or have a minimal damaging effect on liver cells. The latter die under the action of immune cells that react to viral proteins that appear on the surface of hepatocytes. The main defender of the body – the immune system, trying to rid the liver of the aggressor, kills its own cells.

The problem of chronic viral hepatitis has long grown from a purely medical to a social one: the number of carriers of the B virus in the world is estimated at 350-400 million, of the C virus – 150-200 million. Any, not only viral, chronic hepatitis is dangerous because long-term progressive inflammation of the liver in some patients leads to cirrhosis with numerous complications, primarily liver failure. Against the background of cirrhosis, the risk of developing a malignant tumor increases many times.Thus, hepatitis, cirrhosis and liver cancer are by no means separate diseases, but an evolutionary chain, which can be broken either by preventing the onset of the disease or by successfully treating an existing hepatitis.
The question arises – should all patients with chronic viral hepatitis be treated? And if the patient came into the doctor’s field of vision already at the stage of cirrhosis, which often happens? A decade ago, this served as a reason for an unequivocal rejection of etiotropic therapy, although it should be recognized that cirrhosis after viral or other chronic hepatitis can sometimes develop relatively quickly, and then stabilize for many years.Here is another paradox – finding itself defenseless against a damaging factor, the liver adapts to existence with it, including hidden compensatory mechanisms.
Today, cirrhosis is considered as a reversible condition, subject to the elimination of the factors that led to its development.

Alcohol.

It is difficult to estimate the true prevalence of alcoholic liver disease for the following reasons: 1) alcohol abuse is often carefully hidden; 2) in the early stages of liver damage, the person has no complaints; 3) there are no absolutely specific signs of alcoholic illness, therefore, the establishment of an appropriate diagnosis is possible only on the basis of the results of a comprehensive examination.At the same time, the statistics of hepatological departments of leading medical institutions indicate that alcoholic cirrhosis accounts for an average of 40% of the total number of patients at this stage of liver damage. Why cirrhosis? The fact is that only when signs of liver failure appear, the “abuser” begins to pay attention to malfunctions in his health: eyes turn yellow, stomach enlarges, nose bleeds for no apparent reason … Unfortunately, these are symptoms of not the first stage of cirrhosis.
Although there is a relationship between the dose of alcoholic beverages and the likelihood of severe liver damage, it is far from linear. The compensatory capabilities of the liver are so great that sometimes all attempts to poison it run into an unshakable obstacle. Of great importance is the genetically determined activity of enzymes that process ethyl alcohol in the body. It should be remembered that not all patients with severe forms of alcoholic liver damage suffer from alcohol dependence. Often they drink for relaxation, keeping company, observing “business etiquette” – that is why there are so many socially successful people among these patients.
Treating alcoholic liver disease is simple only at first glance: giving up alcohol is identical to eliminating the causative factor. However, according to authoritative experts, having learned the diagnosis, the majority of patients reduce the dose, but only every seventh (!) Completely refuses alcohol. In addition, in the later stages, perverted immune reactions aimed at alcohol-damaged hepatocytes are connected to the destruction of liver cells, so that even a radical change in lifestyle does not stop the course of the disease.

Disorders of nutrition and metabolism.

We are talking about obesity, type 2 diabetes mellitus (obesity diabetes), fat metabolism disorders. All this is united by the concept of “metabolic syndrome”, in the pathogenesis of which the liver is far from the last place. Relatively recently, the concept of “non-alcoholic fatty liver disease” has appeared, which, as it turned out, affects millions of people in economically developed countries. This is facilitated by the “Western” way of life: little movement, a lot of fatty and sweet.In addition to the cardiovascular system, the liver also suffers, unable to cope with the overflowing fat. Fat is a strategic source of energy in the body, and like any fuel, it is potentially dangerous. Excess fat causes inflammation, that is, hepatitis, which in severe cases leads to cirrhosis. In metabolic syndrome, the liver, synthesizing dangerous fat-containing substances, is in the role of both the aggressor and the victim.
What to do? To be treated, to gradually lose weight (in no case starving), to normalize the sugar and fat content in the blood, to protect liver cells. It should be remembered that fast weight loss is more harmful to the liver than slow obesity. If we simplify the complex cascade of biochemical processes as much as possible, we can imagine that during starvation, fat, leaving the subcutaneous depot, enters the bloodstream, from where it is captured by liver cells. The same applies to surgical interventions leading to dramatic weight loss.

Medicines.

The number of prescribed drugs is growing from year to year. Here are some statistical facts: side effects of drugs are the cause of jaundice in 2-5% of hospitalized patients, 40% of hepatitis in patients over 40 years of age and 25% of cases of acute liver failure.The so-called “cryptogenic” (ie, caused by an unknown causative factor) hepatitis often turns out to be just medicinal. The above statistics apply not only to officially registered medicines, but also to numerous dietary supplements and so-called folk remedies. Experts know that the division of drugs into “natural” and “chemical” is more than arbitrary. Suffice it to cite as an example lily of the valley or hellebore berries containing cardiac glycosides, an overdose of which can cause severe poisoning.Even seemingly harmless vitamins can be harmful: for example, a combination of vitamins A and E in high doses can lead to liver damage.
Medicinal lesions of the liver, as a rule, proceed in an acute form, while, however, often not accompanied by any clinical manifestations. Chronic drug hepatitis, and even more so cirrhosis, is an extremely rare situation. Another question is that often a patient, especially an elderly one, receives a dozen or a half medications, each of which can potentially cause hepatitis … The most difficult situation arises when it is impossible to cancel the medication prescribed for health reasons.We have to choose the “lesser of two evils”: if hepatitis does not threaten liver failure, drugs that protect the liver are prescribed.

The listed factors do not exhaust the causes of liver damage, however, they not only occur much more often, but also belong to the category of modifiable ones.