A 40-year-old woman comes to the clinic due to fatigue and generalized weakness for the last 3 months. She has vague, intermittent right upper quadrant abdominal discomfort without pain, nausea, vomiting, or diaphoresis. The patient also reports low back pain and bilateral knee pain. She has had no weight loss or stool changes. Her other medical problems include polycystic ovarian disease, type 2 diabetes, and hyperlipidemia. The patient's menstruations are regular, and she does not use any hormonal contraception. Her medications include glyburide and metformin. She stopped taking a statin due to muscle cramps. The patient drinks 1 or 2 beers (350 mL each) every weekend. Her father was diagnosed with gallbladder carcinoma at age 65. Her mother has hypothyroidism and vitiligo.
Blood pressure is 142/78 mm Hg and pulse is 92/min. BMI is 36 kg/m². Examination reveals an obese and nontender abdomen. The right knee has mild crepitus. Pinprick sensitivity is decreased below the knees, and the ankle reflex is absent bilaterally.
Laboratory results are as follows:
Ultrasonogram shows gallstones and a hyperechoic, enlarged liver with a 16-cm span. There is no gallbladder wall thickening or pericholecystic fluid.
Which of the following would most likely improve this patient's liver condition?

Question

A 40-year-old woman comes to the clinic due to fatigue and generalized weakness for the last 3 months. She has vague, intermittent right upper quadrant abdominal discomfort without pain, nausea, vomiting, or diaphoresis. The patient also reports low back pain and bilateral knee pain. She has had no weight loss or stool changes. Her other medical problems include polycystic ovarian disease, type 2 diabetes, and hyperlipidemia. The patient's menstruations are regular, and she does not use any hormonal contraception. Her medications include glyburide and metformin. She stopped taking a statin due to muscle cramps. The patient drinks 1 or 2 beers (350 mL each) every weekend. Her father was diagnosed with gallbladder carcinoma at age 65. Her mother has hypothyroidism and vitiligo.
Blood pressure is 142/78 mm Hg and pulse is 92/min. BMI is 36 kg/m². Examination reveals an obese and nontender abdomen. The right knee has mild crepitus. Pinprick sensitivity is decreased below the knees, and the ankle reflex is absent bilaterally.
Laboratory results are as follows:

Ultrasonogram shows gallstones and a hyperechoic, enlarged liver with a 16-cm span. There is no gallbladder wall thickening or pericholecystic fluid.
Which of the following would most likely improve this patient's liver condition?

Quizplus · Accepted Answer

11ec193a_97fa_18b0_853d_d5d901718eb4_MD0002_00 This patient with morbid obesity, diabetes, and hyperlipidemia who presents with a mild aminotransferase elevation and hepatomegaly likely has nonalcoholic fatty liver disease (NAFLD). NAFLD is a diagnosis of exclusion; it is marked by the presence of hepatic steatosis not due to a secondary cause (eg, heavy alcohol use). It is the most common cause of liver disease in Western industrialized countries, likely due to the widespread prevalence of metabolic syndrome (eg, central obesity, diabetes mellitus/insulin resistance, hyperlipidemia, and hypertension) that is a risk factor for the disease. Patients are often asymptomatic but can have nonspecific symptoms (eg, fatigue) with mildly elevated aminotransferases and aspartate aminotransferase/alanine aminotransferase (AST/ALT) ratio <1. After other causes of steatosis are ruled out, diagnosis is usually made clinically with noninvasive techniques (eg, ultrasound, CT scan, MRI) showing a fatty liver. Patients in whom diagnosis is unclear may require liver biopsy. NAFLD can progress to fibrosis and cirrhosis. Treatment involves addressing comorbidities (eg, diabetes, hypertension, hyperlipidemia) as well as promoting aggressive lifestyle changes, including gradual weight reduction (rapid loss can worsen NAFLD), exercise regimen, and increased aerobic activity. (Choice A) Alcoholic liver disease typically causes an AST/ALT ratio ~2:1 and presents in patients with significant alcohol consumption (eg, >15 drinks/week for men and >10 drinks/week for women). (Choice B) Iron chelation therapy is indicated for hemochromatosis, which can be associated with hepatitis, arthritis, and diabetes mellitus. However, premenopausal women are unlikely to develop symptomatic iron overload from hemochromatosis due to the regular iron excretion during menses. In addition, arthritis found in hemachromatosis is classically noted in the second and third metacarpophalangeal joints; this patient's knee and back pain are likely obesity-related. (Choice C) Hypothyroidism can cause fatigue and weakness; however, this patient has subclinical hypothyroidism (elevated TSH with normal free T4), which does not typically cause symptoms. True hypothyroidism is also associated with weight gain, irregular menses (in contrast to this patient's regular menses), constipation, and cold intolerance. (Choice D) Primary biliary cholangitis can cause fatigue, hyperlipidemia, and hypothyroidism and is treated with ursodeoxycholic acid. However, it typically causes a markedly elevated alkaline phosphatase and pruritus. Educational objective: Nonalcoholic fatty liver disease is commonly associated with metabolic syndrome (diabetes, hyperlipidemia, hypertension, and obesity) in patients with minimal alcohol history. Patients should be counseled for gradual weight loss and optimal control of diabetes and hyperlipidemia to help prevent or slow the progression of cirrhosis. __________ References: Diagnosis and evaluation of nonalcoholic fatty liver disease. (http://www.ncbi.nlm.nih.gov/pubmed/22110476) Nonalcoholic fatty liver disease: a review of the spectrum of disease, diagnosis, and therapy. (http://www.ncbi.nlm.nih.gov/pubmed/21947639)

A 40-Year-Old Woman Comes to the Clinic Due to Fatigue