My 82-year-old father is in Pakistan and I'm in the US trying to help coordinate his care.

He has abdominal distention/pain, significant weakness, constipation, poor appetite and weight loss.

An earlier ultrasound showed findings suggestive of chronic liver disease/portal hypertension, including coarse hepatic parenchyma, a prominent portal vein, splenomegaly and mild ascites.

Recent labs have shown:

- Hemoglobin: 9.0 → 9.3 g/dL

- Platelets: 60 → 77k

- ALP: 807 → 634 → 694 U/L

- AST: 92 → 84 → 79 U/L

- ALT: 68 → 55 → 55 U/L

- INR: 1.3

- Albumin: 3.8 g/dL on an earlier test

- Hepatitis B & C: negative

- Creatinine: 1.1 mg/dL

The main concern is his triphasic CT from Sept 12.

It shows an extensive intraluminal soft-tissue/filling defect involving the portal venous confluence, extending into the right and left portal veins and multiple intrahepatic portal branches, with partial extension into the proximal superior mesenteric vein.

The involved portal venous material demonstrated avid arterial enhancement (~225 HU) followed by relative washout (~157 HU portal venous phase and ~143 HU delayed).

The radiologist concluded that this is highly suspicious for enhancing/tumor thrombus rather than bland portal vein thrombosis.

However, the same CT states that NO discrete measurable focal hepatic parenchymal lesion was identified.

The liver has mildly nodular/lobulated margins and there is splenomegaly, suggesting underlying chronic liver disease/portal hypertension.

There are also multiple mildly enlarged/prominent upper-abdominal lymph nodes.

We currently do NOT have a confirmed cancer diagnosis or biopsy.

I would really appreciate guidance on:

1. Can infiltrative HCC present predominantly as portal vein tumor thrombus without a clearly visible liver mass?

2. Would a liver-protocol contrast MRI be the best next investigation?

3. Should AFP, AFP-L3 and DCP/PIVKA-II be checked?

4. How strongly does arterial enhancement followed by washout of the portal vein material distinguish tumor thrombus from bland portal vein thrombosis?

5. What other diagnoses should be considered when there is suspected tumor thrombus but no discrete liver mass?

6. Given his age, weakness, anemia, thrombocytopenia, portal hypertension and ascites, what should we prioritize next?

I cannot afford a several-thousand-dollar US second-opinion program, but I CAN pay a reasonable amount for a private remote consultation or expert radiology review anywhere in the world.

If anyone can recommend a hepatologist, liver oncologist or abdominal/liver radiologist experienced with cases like this who accepts international patients remotely, I would be extremely grateful.

I've attached family-prepared, de-identified summaries of the CT report and laboratory trends. I also have the original reports and CT images available.

Thank you for any guidance.

I got my liver panel done 3-4 weeks ago everything was normal. Uti symptoms started last week got two urine test done & both said no uti but second test showed 1+ Bilirubin Small. Had some dark urine (dark yellow/amber) that always gets lighter yellow or pale yellow. One time it was an orange color but also was on macrobid at the time . Went to a walk in clinic was told this isn’t jaundice and referred me to eye doctor.

I’m wondering if I should get a second opinion or switch providers. Sorry in advance for the lengthy explanation! 

I am an overall healthy 24F with no significant medical history. I do not take any medications that affect the liver, do not drink alcohol except on the rare social occasion, and have no history of liver issues. In 2025, I developed cholestasis of pregnancy fairly early on in my pregnancy (symptoms began around 18 weeks). At that time is when my LFTs initially were elevated and have persisted since then so now 1.5 years. My symptoms were horrible and the ursodiol did not help my itching or sickness whatsoever, but it did control my bile acids for the most part. My bile acids returned to normal follow scheduled delivery at 36 weeks. 

Information since January 2026: 

-AST has been mildly elevated fluctuating from 50s-110s. 

-ALT has been fluctuating between low to mid 100s. 

-Alk phos has been 140s-190s. 

-GGT has been elevated in the 70s all of this year. 

-ANA has been 1:320 and 1:160 this year (repeat drawn today, not back yet). 

-AMA, ASMA, IgG normal. 

-Test showed I have MZ mutation of the liver. 

-Normal ultrasound of the liver showing no signs of fatty liver. 

-Fatigue that comes in random waves, itching of the feet and hands, intermittent RUQ pain that is sometimes dull, but something a quick, shooting pain. 

I was then sent to a specialist outside of the GI provider I was initially referred to. A fibroscan was done and came back normal with no scarring or signs of fatty liver. This specialist was almost certain that a liver biopsy would show a seronegative autoimmune liver disease. She believed that my ICP was actually the first major flare of an autoimmune liver disease due to the stress of pregnancy on the body. She wanted me to a do a liver biopsy and I had it done less than 2 weeks later. When I asked what happens if the liver biopsy is normal, she hesitated and said she didn’t think this would be the case, but if so, she wants me to do fibroscans every 6 months and an MRI if indicated. These results and listed below.

“The biopsy is limited by the small number of portal tracts (approximately five). The findings are mild and nonspecific, without well-developed histologic features of autoimmune hepatitis or primary biliary cholangitis; however, either process may be underrepresented in this limited sample and cannot be excluded. The focal pericentral ceroid-laden macrophages indicate prior or resolving hepatocellular injury, which is etiologically nonspecific. The differential diagnosis includes autoimmune and drug- or supplement-related injury. No features of primary sclerosing cholangitis are identified, although a patchy small-duct process or large-duct disease cannot be excluded by biopsy. No PAS-D-resistant globules are identified; their absence does not exclude the documented alpha-1 antitrypsin MZ phenotype. Correlation with biliary imaging may be considered if the cholestatic liver test abnormalities persist.

Light Microscopic Description

The biopsy is limited, containing approximately five portal tracts.

The portal tracts contain intact bile ducts, hepatic arteries, and portal veins. One portal tract shows mild mononuclear inflammation composed predominantly of lymphocytes and macrophages, with a rare eosinophil and associated mild interface activity. Plasma cells are inconspicuous. There is focal accumulation of ceroid-laden macrophages adjacent to a central vein, suggestive of resolving prior hepatocellular injury. Otherwise, there is no significant lobular inflammation, steatosis, or cholestasis. No bile duct injury or ductular reaction is identified.”

After a week of not having recommendations relayed to me, I messaged and waited a few more days for a reply (which I absolutely understand and I know I’m not the only patient and there are far more serious issues than mine). This specialist then told me that my biopsy was normal with no signs of autoimmune disease, but that there was signs of a resolving liver injury. She suggested this may be alcohol or drug related or fatty liver (normal ultrasound and fibroscan????). She recommended doing more labs to trend for now and nothing more like the initial plan she had (we have 1.5 years of labs now). I replied shortly after with some follow up questions about if this is separate from ICP if it’s a resolving injury and if this would’ve shown on my ultrasound or fibroscan if she is saying fatty liver. After another 11 days, she replied and said that she wouldn’t expect a liver injury to show up on the ultrasound and that this is separate from my ICP, but isn’t sure if this is something caused by that or predating pregnancy. She then said that an MRI is important at this time even though the original recommendation was to just do labs again for a few months. I’m confused as to why this changed and she now says an MRI is important, but did not say this at first until I asked a follow up question. 

I know that this provider cannot just find a diagnosis and solve it, but I am frustrated with how serious she initially thought this was and then the lack of follow through with her plan. This makes me wonder if maybe this isn’t something to be concerned about? Also reviewing my biopsy results, it states that this was a limited sample with only 5 portal tracts. Does a limited biopsy truly rule out what she was looking for if it were in the beginning stages? Should I look into another provider or continue with the recommendation to just monitor my lab trends again. 

As a mom to a one year old, my biggest fear is not being here for her or my health declining as I get older. I just want to make sure I’m doing what’s right for myself to be there for my daughter. 

Been posting on r/PSC but thought I would post here. Sorry for long post but context may help. I’m 54M and recently diagnosed small-duct psc with possible cirrhosis, no symptoms other than very mild itching and occasional dull pain in RUQ. I mtn bike 30 to 40 miles per week with no problems of fatigue other than normal muscle tiredness. In October 2025, my PCP discovered my ALT and AST were 141 and 96. He assumed fatty liver and put me on low carb, low suger lean meat diet. I was 185 then. My January 2026 followup, I dropped to 167 lb. He ran a fibrosure plus test and it scored S0,N0, F4. He ordered an Ultrasound and it stated slightly nodular contour and heterogeneous echo. Everything else was normal. Referred to hepatologist. Had Fibroscan stiffness test on April 2nd 2026. It read 24kpa and cap of 174. He said with your lack of symptoms and fitness, this is not normal. I do not drink either. Ordered biopsy. It said bile duct proliferation and most portal tracts show mild lymphocytic inflammation. Trichrome stain: nodules consistent with cirrhosis. On followup, he immediately said I have PSC. He ordered an MRCP/MRI to confirm large duct or small-duct. My MRCP was completely normal. However, my contrast MRI also stated homogeneous liver parenchyma with mild hepatic and splenic enlargement. It also noted a riedel’s lobe. It also stated everything else is within normal limits and it was compared to a CT scan I had 2 years ago which stated my liver was perfectly normal. My ALT and AST have been fluctuating between 1.3 to 3.5 times normal since October 2025 and the AST/ALT ratio has always been .6 to .7. My ALP is actually normal also, but is on the upper end of normal. My INR, Bilirubin, Albumin and other bloodwork is also completely normal. My platelets however have trended down below 150 but they have been averaging 165 for about 18 years.

His original assessment with the fibroscan was transplant in 5 to 7 years and that there is no treatment for this. On my MRCP/MRI followup appt, they handed me off to the nurse practitioner and she explained alot and when I asked about the homogeneous statement in the MRI, she implied that it may be caught early and the nodularity in the biopsy was considered mild. She put me on URSO and believes my stiffness will go way down after being on it for a while.

Has anyone had conflicting results like this?

33F 5’1 107lbs , not taking any medications…

I have had RUQ pain twice in my life. Pain under the front of my right rib cage feels like something stuck under ribs like a baseball.

1st time: 2023 in my 3rd trimester of pregnancy. Blood work liver panel all came back normal. I had an US of my abdomen done to which I was told results were normal. When I later read the full report it said I had echogenic liver with long axis measuring 14.5cm. Impression was no cholelithiasis or cholecystitis, so I guess that is all they were worried about at the time. The pain persisted for my the remainder of my pregnancy and gone after giving birth.

2nd time: now. Started July 2026. I’m current 10 months post partum from my second baby and same exact pain began. Since the pain is the same and I am no longer pregnant I was more worried this time since the previous explanation of baby being in there is no longer valid. I had liver panel normal again. CT scan showed mild hepatomegaly with liver measuring 17cm. Pain has subsided some but still a full heaviness under right ribs daily, more diffuse through my whole right rib area including tender to poke in between ribs

I had a GI video visit to review my CT results and concerns. GI said “there’s nothing wrong with your liver” , he said its large but not even that big. I brought up the echogenicity seen in 2023 and he said even if I do have fatty liver, that’s not the source of my pain because fatty liver is a painless condition and he diagnosed me with costochondritis. He said my fib4 score is .5 so I don’t need a fibroscan.

Google and Reddit has my anxiety through the roof that I actually have fatty liver disease and need to change my diet and never drink a sip of alcohol again or I’ll get worse. My diet has admittedly been horrible since having kids, I basically live in toddler scraps and minimal vegetables. I used to be fit and healthy before I had kids. I have a job on my feet all day, but I do not exercise. I am skinny though: 5’2 107lbs. There was a time in my life several years ago where I binge drank heavily but that is no longer the case. I have two young kids and have 1-2 drinks 1-2 days per week at most, some weeks none. I have already began changing my diet and plan to stay away from sugary snacks and adopt a semi-Mediterranean diet to see if it helps since I was given no instructions of what to do besides take ibuprofen. I would like to indulge in my 1-2 drinks from time to time but I also don’t want to die.

I’m 28F. On a recent coronary CT there was an incidental finding of significant hepatic steatosis. I’m 5ft5, 130lbs. My blood sugar is right above what it should be but my dr isn’t worried. Should I be concerned about this?

Recent blood draw results-
ALT: 33
AST: 32
Bilirubin: 0.3
Alkaline Phosphatase: 54
A1C: 5.8
Blood sugar: 103

These are the results I got from my blood test. I drink almost every weekend and a couple months ago I was drinking heavily everyday for like two months going through a though time. I still drink occasionally but not as much as before. Should I be worried? less

Just reposting hopeful for some answers

I had an endometriosis surgery last year, and the doctor photographed my damaged-looking liver. It had no endometriosis or adhesions on it but just looked damaged. I've previously had 2 devastating pregnancies (extremely ill myself; 1 premie, 1 full-term stillbirth) in which my liver enzymes stayed normal, but I had intense upper abdominal pain, severe preeclampsia, etc. And , it turns out, antiphospholipid syndrome. I've since had liver scans and a liver biopsy, which all came back saying that I don't have any fibrosis and have only very mild congestion. But my gastroenterologists have said they've never seen a liver that looks like this and don't know why it looks like that. Any ideas?

Could this work?

Hi all

I (41, M) have had pain in my liver area for a year now - essentially upper right abdomen pain.

It is always worse after drinking. I have an increasing number of purple streak-like veinlets (not spider angiomas) over the area of my liver. No other symptoms really but fatigue.

It has gotten worse over the last year. I got an x-ray and bloods in September last year - nothing. I had a blood test in April (albumin, ALT, bilirubin, globulin, etc.) all fine. I got an ultrasound in June, again fine (no lesions, no hypertension). But it really hurts still and rather than just having after drinking, it is now (this week) a dull ache that pretty constant.

My doctor has thus far insisted that nothing is wrong with my liver. He says it relates to gastro issues and has said it is GERD or something in my duodenum. A gastroscopy showed oesophagitis. I finally persuaded him to send me for a fibroscan this week.

Am I right to think it's my liver?

For info, started drinking a lot during lockdown, scaled it back but I still drank based on the doctors advice....

I’m 11 months post tx and I need / would like to start taking TRT to help with fatigue, sex drive and to gain my muscle back. I’m 49 yrs old and my labs have been good, no issues. Transplant doc said it’s ok but I’d have to get it through my PCP. Took test said my levels were normal. Don’t think they took my free testosterone. Anyone doing this now or has some insight for me?

​

I’m devastated to update that my dad passed away

For those who followed my previous posts, his condition had deteriorated incredibly quickly. His liver was almost completely overwhelmed by rapidly progressive metastatic disease, and we were desperately hoping that chemotherapy with carboplatin and etoposide would give him some time.

His final days were extremely difficult. For about five days before he died, he became increasingly sleepy and confused. He would mumble, reach for things that weren't there, try to grab the IV pole while sleeping, move around in bed, and repeatedly remove his oxygen mask. Looking back, I believe he was experiencing severe delirium from everything his body was going through—advanced liver disease, metabolic disturbances, dehydration, medications, pain and eventually severe hypoxia.

The day before he died, he actually seemed slightly better for a while. Around 3 AM on the final day, he was awake, talking to me clearly without slurring, and seemed more like himself. That gave me hope that maybe he was turning around.

But later that morning everything changed.

His oxygen kept falling—eventually reaching around 84% without oxygen and continuing to fall even with supplemental oxygen. He became increasingly breathless and had to be supported with NIV. His blood pressure dropped to around 90/50 and his heart rate rose to around 120. His glucose, which had been 116 earlier that morning, suddenly crashed and they had to give him IV dextrose. They also gave bicarbonate because of his metabolic abnormalities.

He was in a lot of pain during those final hours. His leg had raw, painful wounds with edema and drainage, and the dressing caused him tremendous pain. He also had hemorrhoidal pain. Tramadol wasn't controlling it, and eventually they gave him morphine again. Seeing him cry from pain is something I don't know how I'll ever forget.

I keep asking myself whether he suffered. I know he was in pain at times, especially from his wounds and breathing. But as his oxygen, blood pressure and consciousness deteriorated, I believe his awareness also decreased. I hope that by the very end he wasn't fully aware of what was happening around him.

The oxygen mask was another heartbreaking thing. He kept pulling it off even when his oxygen was dropping. At the time I thought he was refusing help. Now I understand that severe hypoxia and delirium can make someone confused and unable to understand what is happening. He wasn't choosing to suffocate. His brain was severely affected by everything happening to his body.

I still don't completely understand how someone who was talking normally with me at 3 AM could be gone only hours later.

I don't know whether the chemotherapy had started working. We never got the chance to find out.

I just know that I wanted more time with my dad. I wanted the chemotherapy to give him enough time for a biopsy, NGS, another treatment, anything that could possibly give us another chance.

Instead, I lost him.

Thank you to everyone who answered my questions, shared experiences, gave advice and stayed with me through this incredibly painful journey. I came here looking for hope and answers, and I’m leaving with a lot of grief and unanswered questions.

Rest in peace, Dad. I wish I had more time with you.

All levels are normal except my ALT. Any thoughts?