A 41-year-old woman comes to the office for a routine follow-up visit. The patient has had malaise and mild abdominal discomfort over the last 3-4 months. Her other medical problems include hypertension, type 2 diabetes mellitus, hyperlipidemia, asthma, and osteoarthritis. The patient also has a history of breast cancer treated with lumpectomy 5 years ago. She smokes a pack of cigarettes daily and drinks 1 or 2 glasses of wine on the weekends. Medications include glyburide, metformin, lisinopril, amlodipine, albuterol, and acetaminophen. The patient stopped taking a statin 2 months ago due to muscle aches.
Blood pressure is 141/78 mm Hg and pulse is 78/min. BMI is 32 kg/m². There is no jugular venous distension. Bilateral scattered wheezes are heard on expiration. The liver edge is palpated 3 cm below the costal margin. No splenomegaly is present. There is 1+ pitting edema of both ankles.
Laboratory results are as follows:
Which of the following is the most likely mechanism of hepatomegaly in this patient?

Question

A 41-year-old woman comes to the office for a routine follow-up visit. The patient has had malaise and mild abdominal discomfort over the last 3-4 months. Her other medical problems include hypertension, type 2 diabetes mellitus, hyperlipidemia, asthma, and osteoarthritis. The patient also has a history of breast cancer treated with lumpectomy 5 years ago. She smokes a pack of cigarettes daily and drinks 1 or 2 glasses of wine on the weekends. Medications include glyburide, metformin, lisinopril, amlodipine, albuterol, and acetaminophen. The patient stopped taking a statin 2 months ago due to muscle aches.
Blood pressure is 141/78 mm Hg and pulse is 78/min. BMI is 32 kg/m². There is no jugular venous distension. Bilateral scattered wheezes are heard on expiration. The liver edge is palpated 3 cm below the costal margin. No splenomegaly is present. There is 1+ pitting edema of both ankles.
Laboratory results are as follows:

Which of the following is the most likely mechanism of hepatomegaly in this patient?

Quizplus · Accepted Answer

11ec193a_97f1_3ef7_853d_539a44155e71_MD0002_00 This patient with metabolic syndrome (diabetes, hypertension, hyperlipidemia, and obesity) who has abdominal discomfort and a mild aminotransferase elevation likely has nonalcoholic fatty liver disease (NAFLD). NAFLD is a diagnosis of exclusion and is marked by the presence of hepatic steatosis not due to a secondary cause (eg, heavy alcohol use). NAFLD resembles alcohol-induced liver injury on histology; cirrhosis is more likely to develop in those with inflammation present (nonalcoholic steatohepatitis) than those without it (fatty liver disease). The underlying pathogenesis of NAFLD is likely multifactorial but may be partially due to insulin resistance, leading to increased lipid synthesis and decreased lipolysis, which cause hepatic steatosis and hepatocellular injury. NAFLD is the most common cause of liver disease in the Western world, likely due to the widespread prevalence of metabolic syndrome, a risk factor for the disease. Patients with NAFLD may have mild to moderate aminotransferase elevations (2-5 times the upper limit of normal). As opposed to alcoholic liver disease, the ratio of aspartate aminotransferase to alanine aminotransferase in NAFLD is typically <1. Iron studies are often abnormal, likely due to chronic inflammation; however, they are not elevated to levels noted in hereditary hemochromatosis (eg, ferritin >1,000 ng/mL, transferrin saturation >45%-50%) (Choice B). (Choice A) Autoimmune hepatitis usually causes a much higher elevation of aminotransferases (ranging from 300-1,000 U/L) than seen in this patient. Also, the negative antinuclear antibody titer in this patient makes this diagnosis even less likely. (Choice C) Increased central venous pressure suggests congestive hepatopathy/cardiac cirrhosis from right heart failure. This patient's lack of elevated jugular venous pressure makes cardiac cirrhosis unlikely. The ankle edema may be caused by amlodipine. (Choice E) Toxin-mediated liver injury (eg, from acetaminophen) often causes marked elevations in aminotransferases ranging from 5-25 times the upper limit of normal, hyperbilirubinemia, and increased prothrombin time. This patient's relatively mild elevations in liver function tests make this condition unlikely. Educational objective: Nonalcoholic fatty liver disease is a common cause of elevated liver enzymes in patients with metabolic syndrome and minimal or no alcohol history. Laboratory abnormalities include mild to moderate aminotransferase elevation (2-5 times the upper limit of normal), with an aspartate aminotransferase to alanine aminotransferase ratio typically <1. Iron studies are often abnormal, likely due to chronic inflammation. __________ References: Adiponectin, a key adipokine in obesity related liver diseases. (http://www.ncbi.nlm.nih.gov/pubmed/21734787) Nonalcoholic fatty liver disease: a review of the spectrum of disease, diagnosis, and therapy. (http://www.ncbi.nlm.nih.gov/pubmed/21947639)

A 41-Year-Old Woman Comes to the Office for a Routine