What your Doctor means...

[Nonmaleficence]

Liver Enzymes:

There are many different ‘liver enzymes’ that a doctor looks at when evaluating a liver function panel (AKA liver function tests). In fact, the liver function panel is not limited to enzymes, it also measures the levels of total protein, albumin, bilirubin, and other molecules that are all produced by the liver and dispersed throughout the body by the blood.

When examining the results of the liver function tests, the total protein and albumin levels will not be altered until there is severe damage to the liver. Severe damage means beyond the level of fatty liver disease and progression to liver cirrhosis. At the point of cirrhosis, the liver is so damaged by fibrosis and scar tissue that the ability of the liver to function as an organ is seriously compromised. Thus, the liver will not be able to produce the proteins/albumin, thus this will be demonstrated on the laboratory test as a decreased blood level of them. The decrease in the amount of proteins/albumin being produced is the reason why cirrhotic patients get ascites (swelling of the abdomen), but that will have to be explained at a different time.

More importantly, what are the ‘liver enzymes’ that your doctor looks at and what do they mean. Well, normally your liver enzymes should remain in the cells of the liver and should only enter the blood stream in tiny amounts. However, when the liver becomes inflamed and damaged by chronic alcohol exposure, then the cells of the liver (hepatocytes) will break down and spill the enzymes into the blood stream. Thus, an elevation of ‘liver enzymes’ is an easy way to determine if your liver has had any damage/inflammation recently.

There are viruses (Hepatitis A, Hepatitis B, and Hepatitis C) that can also cause inflammation in the liver and increase your blood levels of liver enzymes, but there is a simple way to differentiate viral inflammation of the liver versus alcoholic inflammation of the liver that is explained in the following paragraphs.

There are two main enzymes that your doctor will look at in your liver function panel (the other enzymes are not as important unless you have gallstones or other forms of biliary pathology). These enzymes are named Alanine transaminase (ALT) and Aspartate transaminase (AST). In the chronic alcoholic patient, these enzymes will be elevated in a certain pattern that is often easy to discern from other causes of liver inflammation (i.e. viral hepatitis). When the doctor compares the blood level of AST to ALT, the AST will often be elevated by a factor of 2 compared to ALT. For example, in a chronic alcohol user the AST level may be about 120 IU/L, and the doctor would expect the ALT level to be about 60 IU/L.

In viral hepatitis (Hepatitis C), the AST to ALT ratio will be closer to a 1 to 1 ratio and the blood levels are often much higher as compared to in alcohol (usually AST and ALT will be greater than 300 IU/L in patients with viral hepatitis).

I hope this helps some of you who were interested in learning a little bit more about the visit to your doctor. Feel free to ask any questions or ask me to explain something that I didn’t go over too clearly.

Nonmaleficence

[nomoredayones]

All my blood tests results came back normal 2 months ago. Does that mean I am ok??

[Nonmaleficence]

It really depends on the whole clinical picture. If you're a young 20-something year old that is generally healthy and exercises and has only been drinking for a short period, then yes. It should be safe to say that you are 'okay.'

However, if you're an older adult, have been generally unhealthy your whole life and have been drinking heavily for more years of your life than not, then it could actually be a bad sign. It could mean that your liver has decompensated to the point that it no longer releases the enzymes from its cells when it is inflamed and cirrhotic, therefore giving a false sense of good health.

In general, liver enzymes are not the best means to determine the 'health' of the liver. The best method, would be to get a biopsy, however, we all know that a biopsy is incredibly invasive and carries with it certain risks secondary to having to cut into the abdominal cavity to get to the liver. Thus, the most cost effective and least invasive means, would be to get an ultrasound to determine the damage that the alcohol has done.

[Adina]

Thank u for posting about health. Id love to hear more about liver failure and ascites. My grandfather had ascites, and I never could understand how/why it happens. Maybe you can explain it better.

[nomoredayones]

Thank you Nonmaleficence. I am in my 40's and I have been drinking heavily for the last 2 years. About 5 years ago, I had a sonogram that included my liver and it was normal. I am hoping I have not stopped drinking too late.

[Nonmaleficence]

@nomoredayones: I'm glad to hear that the ultrasound of your liver didn't show any abnormalities. It is never too late to stop drinking. You sound like a healthy person and have a lot of life yet to live

@Adina: I'd be glad to write about ascites. As you may have been able to tell, I have had a personal interest during my medical training to focus on pathophysiology related to alcohol. I truly enjoy being able to spread this knowledge to everybody on this forum whom I have learned so much from, particularly when it comes to each individual story and what has worked (or not worked) when it comes to remaining abstinent. PS it will take me a couple of days to put together a well written paper on the subject, so I hope you can be patient with me.

[Nonmaleficence]

Hey John,
I agree with you. I wouldn't feel like I was in the clear until I got an ultrasound of my liver (to make sure you haven't progressed to fatty liver disease or beyond). If the ultrasound comes back normal, then that combined with your amazing lipid panel and liver enzymes you should feel very good about your health. The only thing you'd have to worry about would be to remain abstinent and stay fit, which sounds like you've been very successful at that so far.

I understand that you are concerned about disclosing your past alcohol use to your doc because of potential insurance issues. And that is quite reasonable. However, depending on how close of a relationship you have with your doc, you could discuss this concern of not wanting a history of alcohol on your medical record and that you would like an ultrasound of your liver. Or you don't even have to mention to him/her about your history and just ask the doctor politely if he can order an ultrasound of your liver because you have been having some pain in your right upper abdominal area and it would really make you feel better to have some imaging of it.

And congrats on staying sober!

[carol]

Doc, if I may call you that, "what if" there are no red flags in the usual liver tests and the patient is now abstinent. If an ultrasound were done, what treatment would be recommended?

I'm not trying to be obstinate, but we worry a lot, tests are expensive. I understand that absent an ultrasound, liver problems can't be ruled out, but I wonder how the treatment would be different without other symptoms, with or without the ultrasound. It is my understanding that the liver has an amazing ability to heal itself, but of course there is a point of no return as well where self-healing may be limited or impossible,

Thank you for sharing your knowledge with us.

[Nonmaleficence]

@John: I definitely had to google 'sword of Damocles.' That's an awesome reference.

@carol: You are absolutely right (except the doc part...I still have 4 months to go). "What treatment would be recommended?" This is the question that MUST be asked every time a test or procedure is ordered in a medical setting. If there is NO benefit (benefit meaning that there is a treatment for the disease the patient may have) to a test or procedure, then it should not be completed. With that logic, there should be no reason for John to get a liver ultrasound since there is no specific treatment (unless we're talking about cirrhosis, which is not the case because this is not how he is presenting i.e jaundice, ascites, spider angioma, asterixis, etc.). However, in this particular case, the benefit would be John's peace of mind. He is concerned that there could potentially be an underlying pathology that he is unaware of because there is a possibility that his other exams (normal lipid panel and liver enzymes) are giving him a false sense of comfort. Thus, it comes down to how much does he want to go through/pay for that peace of mind.

Awesome questions everybody!

[nomoredayones]

If someone (like me) had all their blood tests come back ormal (kidney function, liver function) and their doctor said "fIne", why would they req

[nomoredayones]

request additional tests like a liver sonogram or a liver biopsy?

[Nonmaleficence]

@nomoredayones - If everything came back 'fine' and they didn't have a reason to suspect an issue with your liver, then there wouldn't be any reason to order a liver ultrasound. Were you able to look at the lab results yourself? If there were only small changes to lab results, then sometimes docs will say that everything is 'fine' just so they don't worry the patient. But the doc will still order another test, just to make sure that he/she isn't missing something.

As for a biopsy, they wouldn't order that unless your liver was really bad off (biopsies are usually saved for last).

[Nonmaleficence]

Cirrhosis and Ascites:

As we already know, the liver has a LOT of functions, and these functions are vital to our survival. One of the largest jobs of a healthy liver is to produce enzymes required to metabolize particles in our blood stream. The purpose of this is to either break down molecules to forms that can be eliminated from the body (such is the case with alcohol and many other drugs/medications), or to change their original form to something that can be utilized by the body (such is the case with proteins like albumin and clotting factors). The liver also has many other functions, however, the components of breaking down and building molecules are the two most important when it discussing cirrhosis.

Cirrhosis is what occurs after repeated injury to the liver which destroys the normal, functional liver cells and replaces it with non-functional fibrosis, nodules and scar tissue. There are many causes of ‘repeated injury to the liver,’ which include alcohol intoxication, hepatitis viruses, autoimmune diseases and many others. Alcohol is the second leading cause of cirrhosis in the United States (the #1 cause is Hepatitis C).

As the liver loses its functional capacity, physical symptoms soon emerge. Some of the more notable symptoms are described below.

Jaundice - yellowing of the skin due to inability of liver to eliminate bilirubin from the blood stream
Itching - due to inability of liver to eliminate bile acids from the blood (there are other causes as well)
Bruising - due to inability of the liver to produce clotting factors
Spider angioma - small bruises on the body, due to elevated levels of estrogen that the liver is unable to break down
Confusion - due to inability of liver to break down and eliminate ammonia products from the blood
Asterixis - flapping of the hands when outstretched, also due to excess ammonia products
Varices - this is the biggest concern for doctors because it can lead to large amounts of blood loss in a short period of time. In cirrhosis, the liver becomes so scarred that even blood has a hard time passing through it, thus causing an increase of pressure in the vessels that travel to the liver. These vessels that are now carrying an increased pressure find a way to release it by either of two means: taking a different path in order to get around the liver, or by bursting open. Hence the concern.

The most important symptom that we will be talking about today is ascites. It is the progressive buildup of fluid in the abdominal cavity that may not be noticeable at first, but eventually leads to an accumulation so great that the abdomen becomes disproportionally larger than the rest of the body.


The cause of ascites can be difficult for some people to explain because it can be tricky and there is a bit of physics involved. However, the physics is simple if explained properly and the small fine details are easy to understand.

The fluid that enters the abdominal cavity gets there via two separate means that are both induced by cirrhosis.

1) The cirrhotic liver loses the ability to produce proteins that are released into the blood stream and travel within the blood vessels of the body. These proteins in the blood cause a force on any fluid outside of the blood vessel to enter the vessel. Basically, the proteins act to pull fluid surrounding a blood vessel in to it. When the liver doesn’t produce these proteins, then you lose that pulling force as well.

2) As we saw with varices, the liver becomes so scarred and fibrotic that the blood that normally passes through the liver freely can no longer do so. Thus, the blood vessels that travel to the liver become congested with blood that has no where to go. The increasing amount of blood within the vessels causes an increased pressure on its walls. Since the blood vessels have microscopic passages in the walls, the increased pressure causes the blood to leak out at a higher rate than normal.

The fluid that leaks out of the blood vessels due to the elevation in pressure is not able to be reabsorbed because the liver is not producing the proteins that cause the pulling force on the fluid to reenter the blood vessels. This fluid accumulates in the abdominal cavity and becomes the physical sign/symptom of ascites.

This really only demonstrates a small fraction of how important the liver is to us. As I’ve seen with so many people before, many will disregard this subject because they don’t think it pertains to them. These are often the people at the greatest health risk. I have yet to learn how to get their attention.

[_Erin_]

Nonmaleficence - Thank you for the info! I always wondered/suspected that my mom had cirrhosis. She had several medical problems including diabetes and to my knowledge, was never formally diagnosed with cirrhosis, but she had the yellow skin and confusion (which was always blamed on sugar lows), and the bloated belly. It literally looked like she was pregnant at 59 years old. I also remember taking her to the emergency room once and walking by the doctor's station, I heard her doc on the phone say, "...she's an alcoholic..." and I always wondered if that was a conclusion he drew himself or if Mom had actually admitted that to him. That day was also the first time I witnessed her sugar drop to dangerous levels. One moment we were having a conversation, the next moment her face went blank and she couldn't answer me. Still gives me chills. I yelled for help and when they came in, I had to sign papers for them to do anything for her, because she wasn't "with it" and her hands were cramped shut. Scared the holy hell out of me.

Anyway, sorry, I went off on a ramble.

It's crazy how I read about things now and realize just how much all of her health problems were tied together. Drinking nonstop for 20 years didn't help any of them. On top of not wanting to go down the same path as far as drinking, it also really bothered me how very little concern Mom had for herself and her own health. It used to piss me off so much that we all loved her, wanted her around for as long as possible, and she just seemed to have no interest. Now that I'm a mommy myself, I have a list the length of my arm of things I want to do differently, or at least to make sure my little girl knows she is #1 in my life and that she is worth the world. One of them is to make sure I don't sweep health issues under the rug or forget that I'M worth something, too. I want to set a good example for her so I am around for her for a lot longer than my mom was, and so hopefully she picks up my good habits.

Man... post one time after a few months and you think you have to type a novel. I appreciate the point of view you have on all this, and am glad you're here to share it, Nonmaleficence!

[carol]

Erin, yay, you're back, at least for a moment! Hope you're doing well!

Doc (I know, almost Doc), thanks for the info.

[Nonmaleficence]

Erin, I know exactly what you mean when it comes to learning about things now and being able to connect the dots with what was going on before. My mom passed away from cancer, and learning about it in school really hit home for me. I finally understood why she wasn't able to speak very well and why she had trouble walking and doing other daily tasks...especially when it got closer to the end. I have a different appreciation for it now.
I'm sorry to hear that you had such a scary moment with your mom...but on the other hand, it's great to hear that you transformed that moment in to not wanting your kids to have to go through the same thing.
It really sucks when you say that your mom had no interest in people trying to help her. I definitely feel it when I try to help my brother.

[nomoredayones]

Thank you for all the information Nonmaleficence. It is sobering (no pun intended) to see the consequences of alcoholism.

[Adina]

Thanks, Mal! Like Erin said...there are a lot of things I couldn't figure out years ago when my grandfather was sick that seem so clear when you discuss these things. And it really helps to keep me motivated knowing what I'm doing to my body.
Keep it up! I have many more questions, but I don't want to bug you.