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"33 yo woman with incidental
right sided abdomenal
discomfort"
James M Sosman, MD
Case History
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ID AG is a 35 yo W woman who presents for
routine evaluation
CC: right sided abdomenal discomfort
HPI: AG states that she has noted discomfort for
the past few months. Pain is dull and nonradiating over the right lateral side of the chest
and abdomen. She states the intensity is 4-5/10.
It is aggravated in some positions but is not
pleuritic and is not associated with food or
exercise. The discomfort is worsened with
palpation over that region.
Case History
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ROS
— She denies fevers, chills, nausea or vomiting,
anorexia, weight loss, jaundice, arthralgias,
myalgias, rash, pruritus, and changes in her
urine or stool. She also denies recent travel
or any “sick” exposures
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PAST MEDICAL HISTORY:
— Anemia
— G0P0AB0
Case History
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MEDICATIONS:
— MVI 1 a day
— Ginseng once a day
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NKAD
FMHx
— No Hx of GI cancers or gallstones
— 60 yo Father with CAD and mild
Diabetes
Case History
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SOCIAL HISTORY:
— Smokes ½ ppd
— occasional alcohol use
— Married
— works as a manicurist
— Denies IDU
— She walks 2 miles/day for exercise
Case
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PHYSICAL EXAM:
— Vitals: BP 139/75, HR 91, RR 16, Temp 96.8 F
Weight 240lbs BMI 38
— HEENT WNL
— Cardiac and Pulmonary exam WNL
— Abdomen- Normoactive BS, no HSM/Mass,
mild discomfort RUQ and Rt lateral Abdomen
with no rebound or guarding
— No LNs
— Skin WNL other than a 2 yr old butterfly tattoo
on her left shoulder
Diagnostic Options?
Case
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Ordered a few lab tests
Advised AG to try Ranitidine 150mg
PO BID
RTC in 3-4 wks or PRN
Case
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Laboratory Studies:
— WBC 10.3, Hemoglobin 12.2, PLT 215.
normal differential
— Sodium 137, potassium 4.5, chloride
101, CO2 27, BUN 16, Cr 1.1, glucose
110
— T Bil. 0.9, Alk phos 136, AST 45, ALT 75
— Urine Pregnancy- neg
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What Next?
Abdomenal Ultrasound
Differential Diagnosis of
Chronically Elevated
ALT?
Differential Diagnosis of Chronically Elevated
ALT
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NAFLD
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— Metabolic syndrome
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Alcoholic liver disease
Hepatitis C
— IVDU, blood
transfusions
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— Endemic area, IVDU,
MSM
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Hemochromatosis
— Family history
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Autoimmune hepatitis
— Family history
Medications
— Exposure history
Hepatitis B
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Alpha-1 AT deficiency
— Family history
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Wilson’s disease
— Family history
Nonalcoholic Fatty Liver Disease
(NAFLD)
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A spectrum of disease predominantly characterized
by macrovesicular steatosis of the liver that occurs
despite little or no consumption of alcohol
— Range of disorders from hepatic steatosis, which is
generally benign, to nonalcoholic steatohepatitis (NASH),
which may progress to cirrhosis and its complications
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Early studies used a strict cutoff of either no alcohol
consumption or < 20 g of alcohol intake per week to
classify as nonalcoholic etiology
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NAFLD represents the hepatic manifestation of the
metabolic syndrome
Metabolic Syndrome
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Characteristics include:
— obesity, hypertension, diabetes,
hypertriglyceridemia, and a low HDL level
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Approximately 47 million in the US have
metabolic syndrome
— > 80% have NAFLD
— > 90% with NAFLD have some features of
metabolic syndrome
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Insulin resistance is the fundamental
pathophysiologic abnormality that connects
NAFLD with metabolic syndrome
Classification of Nonalcoholic Fatty
Liver
NAFLD: Epidemiology
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Approx 33% of the US population has hepatic
steatosis
— Prevalence
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Hispanics 45%
Blacks 24%
In an autopsy series, hepatic steatosis in 2.7% of
lean individuals and 18.5% of obese individuals
Studies published before 1990 emphasized that
NASH occurred mostly in women (53% to 85% of all
patients)
— In more recent studies NASH occurs with equal frequency
in males
Relationship between BMI, waist
circumference, and the presence of
NAFLD
NAFLD is directly related to BMI: More than 80% of individuals
with a BMI > 35 have steatosis
Waist circumference may be an even better predictor of
underlying insulin resistance and NAFLD than BMI
Common Symptoms Among
Individuals With NAFLD
Laboratory Abnormalities
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7.9% of the US has persistently abnormal
liver enzymes despite negative tests for viral
hepatitis and other common causes of liver
diseases
— related to BMI and other risk factors associated
with NAFLD
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Elevated ALT level (1-2 fold increase) most
common liver enzyme abnormality
— elevation is usually modest (rarely > 300 IU/L)
— AST-to-ALT ratio is typically < 1
Natural History of NAFLD
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Most studies are cross-sectional with highly
selected patient populations
Increased risk of cardiovascular mortality
Was initially believed that NAFLD rarely
progressed to more advanced liver disease
— Steatosis may progress to more advanced liver
disease in < 5%
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NASH, however, can progress to cirrhosis
— In a study of 103 individuals with NASH who had
multiple liver biopsies taken over a median duration of
3.2 years, 37% showed fibrosis progression and 29%
showed regression
— Risk of NASH progression to cirrhosis is 20%
Natural History of NAFLD
Pathophysiology of NAFLD
Evaluation
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Most of the time NAFLD is identified
incidentally
— 45-80% of patients are asymptomatic
— Patient may have an abnormal ALT
— Persistent hepatomegaly without an
obvious cause
— abdominal imaging performed for
unrelated reasons reveals a fatty liver
Evaluation: Noninvasive methods
for the diagnosis of NAFLD
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Hepatic Ultrasound
— increased hepatic parenchymal echotexture and vascular blurring
— sensitive (85% to 95%)
— 62% positive predictive value
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Hepatic CT Scan
— Hepatic steatosis decreases CT attenuation of the liver (10 or
more Hounsfield units lower than the spleen on a noncontrastenhanced scan)
— 76% positive predictive value
None of these methods can diagnose steatohepatitis or
accurately assess the stage of the disease
How to Evaluate an Individual for
the Presence of NAFLD
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Exclude alternative causes
Assess for features of metabolic
syndrome
Non diagnostic imaging (US)
Consider assessing for presence of
steatohepatitis (Liver Biopsy)
Conditions and Factors
Associated With NAFLD
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Metabolic Syndrome
Drugs (amiodarone, tamoxifen,
antiretroviral meds)
Wilson’s Disease
Jejuno-ilealbypass surgery
TPN
Drugs Used for the Treatment of
NASH
Case
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AG was told of her presumptive diagnosis
(NAFLD)
She was informed to avoid potential
hepatotoxins
AG was referred to a dietician and started
on an aggressive exercise program
AG will try to stop smoking
She will follow up with me in about 2
months to assess progress and obtain
fasting lipids