Tag: alkaline phosphatase

You Give Your Blood, You Pay the Bill, So Get the Results!

Do you know why I could report my lab scores in my last post? Simple: I tell my doctors I want a print out of my bloodwork results. For years I never considered doing this, but at some point I got fed up with throwing out my arm for yet another needle, getting the bill for the copay –and having nothing concrete to show for it.

Moreover, I felt that going from doctor to doctor there was a risk of no continuity, no history, no comparisons, no full use being made of the data available. And there were some oddities I felt needed investigating and explaining.

I’ve had conscientious doctors and I have had blunderers. And I’ve finally recognized the obvious (well, when it comes to adults, anyway):

No matter how good your doctor is, no one, and I mean no one, cares about your health as much as you do.

So get your results and hold onto them. It would be nice to have a Permanent Record, like the legendary thing that people my age always heard about in school (better not do x,y, and z: it will go on your Permanent Record), with all your health info, all that data collected at great expense, readily available, but there is no such thing. The best you can do is get hold of the few scraps the medical system is willing to give you — or to let you purchase.

You may not understand all of it (I sure don’t), but you can learn a lot on the net. The big thing though is to note any Hs [Highs] or Ls [Lows] or highlighted or checked lines, look at the normal range, and if your numbers are way off,  ask your doctor, what do these scores mean? If she says it is something to watch, then you watch it too.

This is what can happen if you don’t:

During my PBC diagnosis odyssey (see last post), I remembered some weirdness that went on when I was hospitalized with pneumonia five years previously in spring 2001. Gall bladder tests were ordered — for pneumonia? I never got an explanation and was too sick at the time to pursue it with either the family doctor who admitted me or the pulmonologist who took over. I had follow-up visits with both after my release, and neither discussed the tests. So I mentally filed it under weirdness. My family doctor quit practicing within the next year or two.

In 2006 I  decided it was time for a closer look. I went to the patient records archives at the hospital I’d been in, and I paid for records of my visit.

This is what I learned: Way back in April 2001, when I had pneumonia,  my alkaline phosphatase (ALP) reading was 445 (norm 39-118). Remember, elevated ALP is one of the, if not the, biggest red flags for PBC. What the doctors I saw in the hospital did was order an ultrasound and CT scan to check out the biliary tract and a HIDA (Hepatobiliary Imino-Diacetic Acid) scan to evaluate the gallbladder. The doctor’s notes for my last day in the hospital allude to waiting on HIDA results and considering an outpatient bone scan, but I never heard anything about these results or further studies.

These wouldn’t have diagnosed the PBC, but that’s not the point: when tests don’t show what the doctor is looking for, then those results should  prompt further investigations. Good doctors don’t just shrug their shoulders and forget the problem that caused them to order tests in the first place.

Moreover, I was never told my alkaline phosphatase levels were out of whack.

Five years would pass before I first heard or saw the words alkaline phosphatase.

What does this mean:

It means I could have been diagnosed with PBC — I could have started treatment –– in spring 2001 rather than winter 2007.

I like to think if I had left the hospital with copies of my labs, rather than returning there 5 years later to get them, I would have asked the right questions: What is this Alk Phos total? Why is it so abnormal?, and that I would have pestered someone until I got some answers.

By the way, the charges for the diagnostic tests no one followed up on: Nuclear Med Diagnostic: $891.25. Ultrasound: $189.25. Nuclear Med: $120.75, CT scan: $1,169.75 = $2371.00. Complete waste.

High ALP + High GGT + High IgM + AMA = PBC

So how did I end up getting diagnosed with primary biliary cirrhosis (PBC) three years ago? It wasn’t easy, believe me.

Stop 1: Family doctor, July 2006

My complaint was that I was more tired than usual. The previous year I had had iron deficiency anemia due to female problems 😦 leading to a D&C. So anemia was what I expected as this year’s verdict as well.

Wrong. My family doctor, Dr. Cindy McAdams, paid close attention to my lab work (in another post I will explain why I think that worth mentioning. Suffice it to say, I have had doctors who haven’t).

My serum alkaline phosphatase (alk phos or ALP) was 410 (normal is 25-153), AST 74 and ALT 91 (0-40 norm).

Explain.

These are liver enzymes. Abnormal  AST and ALT are linked to a number of conditions and frequently occur in connection with the use or misuse of scores of medications. A mild to moderate elevstion, like I had, is seen in PBC, but is not a crucial bit of information.

Markedly elevated alkaline phosphatase is, and a score of 410 when 153 is top normal is not good. From MedicineNet:

Abnormally high blood levels of alkaline phosphatase may indicate disease in bone or liver, bile duct obstruction, or certain malignancies. The enzyme is often elevated in the leukemic cells in chronic myelogenous leukemia.

A repeat of the bloodwork with additional tests added yielded more bad marks, including a 68 Westergren sedimentation rate (upper norm of 20) and low platelets and white blood count, and I was packed off to a haematologist (specialist in blood disorders).

Stop 2: Hematologist, August 2006

This stop proved useful to rule some things out. The hematologist started with an ultrasound, and that revealed a much enlarged spleen — and enlarged lymph nodes. Things had taken a grim turn indeed, and a CAT scan was ordered to establish whether there was activity in these enlarged lymph nodes. Now I am not a medico, but I know what activity in the lymph nodes could have indicated: cancer.

I was lucky, however, and not sorry to be sent along from that office; the hematology and oncology units were housed together, and it was a place I didn’t want to belong.

I did leave with some new findings:

  • Markedly elevated GGT (585 when normal is 7-32). GGT stands for gamma-glutamyl transferase. High ALP with normal GGT means that the trouble is a bone disease; high ALP and high GGT narrow it down to bile ducts or liver.
  • Immunoglobulin IgM was 810 (norm 40-230). This is what I found out: “Increased serum immunoglobulin concentrations occur due to polyclonal or oligoclonal immunoglobulin proliferation in hepatic disease (hepatitis, liver cirrhosis), connective tissue diseases…”

Stop 3: Rheumatologist, September 2006

I had enough findings to make lupus or rheumatoid arthritis a possible if not exclusive diagnosis, and so I visited the rheumatologist and left behind who knows how many vials of my blood. My ALP was now 481, and other bad marks were added to my lengthening list:

  • Actin (Smooth Muscle) Antibody of 115 units when norm is 0-19. Enter a new possible diagnosis: autoimmune hepatitis.
  • Presence of antimitochondrial antibodies (AMA), and “between 95 and 98% of patients with primary biliary cirrhosis (PBC) have autoantibodies (antibodies to self) in their blood that react with the inner lining of mitochondria.”

Stops 4 & 5: Gastroenterologists, October to November 2006

At this point I should have seen a hepatologist, a specialist in liver diseases, but since there isn’t one locally, a gastroenterologist was the fallback.

Two stops here because the first GI I visited ordered his own bloodwork, gave me an appointment date two weeks later, and when I arrived, he was not. Yes, I know emergencies happen. But when his staff offered to reschedule me in the new year, his first available appointment since he would be out of the country in December, I said no way, just give me my records and I’ll find someone else. They told me to hold on a minute, and came back with the news that another doctor in the practice would see me in an hour.

His approach was to pursue the possibility of autoimmune hepatitis (AIH). We were pretty much down to two choices: that or PBC. And 7 of 10 people with AIH go into remission after 3 years’ treatment. People with PBC don’t.

So the plan was to give me prednisone, and if I responded to this steroid, it was likely I had AIH. If not, then we were left with PBC.

So I took prednisone for 6 weeks.

Maybe you’ve seen it in old British movies: back when that country still had capital punishment, if the judge was going to announce a sentence of hanging,  he entered the court he wearing something like a black piece of cloth atop his white wig. GI2 may as well have been wearing one of those when he came into the examining room. My scores were worse.

Then he did the best thing and the dumbest thing he could.

The best was that he set me up an appointment with a hepatologist at the University of Alabama in Birmingham Medical School. The dumbest was he simply stopped the prednisone.

When you’ve taken 40 mg of prednisone daily for 6 weeks, it is not a good idea to go cold turkey, to abruptly entirely withdraw it. I spent the next month practicing being dead.

Stop 6: Hepatologist, December 2006

I first visited the hepatologist the week before Christmas. All the puzzle pieces were ready to put into place:

An elevation of the aminotransferases alanine aminotransferase (ALT) and aspartate aminotransferase (AST) may be identified in most patients with primary biliary cirrhosis, but significant elevations of the alkaline phosphatase (ALP), g -glutamyl transpeptidase (GGTP), and immunoglobulin levels (mainly immunoglobulin M [IgM]) are usually the most prominent findings….AMAs can be found in 90-95% of patients with primary biliary cirrhosis, and they have a specificity of 98% for this disease.

  • Elevated ALP √
  • Elevated GGT √
  • Elevated IgM √
  • Elevated ALT √
  • Elevated AST √
  • Presence of AMA √
  • The hepatologist started me on 1000 mg of Urso Forte a day.

    January 2007

    A month later my ALP, which at its highest was 481, had returned to the upper limit of normal (on this lab’s scale [they vary]): 117.

    November 2009

    My ALP is still 117. Just how meaningful this is remains to be seen.

    Varicose Veins in my Esophagus?

    “And if the dam breaks open many years too soon…”


    I was doing a pretty good job of cultivating indifference toward my bad luck at having somehow acquired primary biliary cirrhosis [PBC], taking my 1000 mg of  Ursodiol most days (sometimes I forget), and not scouring the internet hourly looking for the article that would tell me my future, confining that process to just the week before what had become an annual appointment at the University of Alabama at Birmingham liver clinic.

    After all, my alkaline phosphatase levels had dropped from the high 400s to the upper limit of normal, 117,  indicating the Ursodiol is doing its job, increasing bile flow from the damaged bile ducts, thereby theoretically slowing the progression of liver damage caused by backed-up toxic bile.

    Typically it would make sense to judge a treatment’s effectiveness  not quite so objectively, but in this situation, I’ve only the numbers to rely on.

    Do I feel better than I did in December 2006 when I started on the Urso Forte (my favorite brand name for a drug, roughly translatable, or so I claim, as Strength of the Bears)?

    Not dramatically. The only symptoms of PBC before the liver is damaged significantly are fatigue and itching, and I never experienced the itching and who among us doesn’t complain of fatigue?

    This week the only bad marks on my blood tests were for ones I’ve scored poorly on for at least four years: low white blood cell count and low platelet counts. In the past, these scores were considered not bad enough for alarm, just an anomaly, perhaps.

    So I was surprised to be told I should have an upper GI endoscopy to detect whether large varices, or swollen veins (like varicose veins), caused by portal hypertension (itself caused by cirrhosis) are in my esophagus. Left untreated these could “burst and bleed into the gut.

    But I gather that an association has recently been made, or at least suggested, between portal hypertension and low white blood cell count (leucopenia), and/or low platelet count (thrombocytopenia). Moreover, in 2006, on the long and wearying road to the PBC diagnosis, an ultrasound showed a very much enlarged spleen, and hypersplenism is another red flag.

    My first impulse was to say no to this test based on a strong and irrational desire not to submit to another test, a resistance that I couldn’t explain and thus ignored.

    Afterwards, after I started processing this new information, that impulse seemed less irrational: if I do have varicose veins in my esophagus, it probably means that I can no longer tell myself that my mostly normal blood test numbers  mean the PBC was diagnosed  and treatment begun in time to escape cirrhosis, at least for a while. It will mean that  my liver is already dying.

    Or so it seems to me. Surprises during doctor appointments frustrate me: I need time to think to know what questions to ask.

     

    Resources for the curious or those in a similar fix:

    A simple intro to PBC is at PBC Foundation

    A much more thorough one is at MedicineNet.com

    The “bad luck” link in the first sentence of this post refers to the rarity of the disease. In “Food for Thought about Primary Biliary Cirrhosis in 2006,” an essay on the website of the UC-Davis Immunology Lab, there’s this statement:

    PBC is thought to be more commonly found in specific areas of the world. In particular, disease frequency varies between 10 and 400 cases per million population. It has been suggested that PBC is more common in northern countries, including England, Sweden, and Northern American states.

    MedicineNet says:

    Studies indicate that the number of people with PBC at a given time (referred to as the prevalence of disease) ranges from 19 to 251 per million population in various countries.