A 45-year-old man is evaluated for abnormal liver tests. The patient has had no nausea, vomiting, diarrhea, or weight loss. He has no significant medical problems, takes no medications, and has never been hospitalized or received blood transfusions. The patient consumes 1 or 2 beers during the week and, occasionally, 4 to 6 beers on the weekend. He does not smoke cigarettes or use illicit drugs. The patient works in a warehouse and is monogamous with his wife.
Vital signs are within normal limits. BMI is 30 kg/m². There is no scleral icterus, lymphadenopathy, or rash. The abdomen is soft and nontender without hepatosplenomegaly. The remainder of the physical examination shows no abnormalities.
The most recent laboratory results are as follows:
Repeat liver function testing shows similar results.
What is the most appropriate next step in management of this patient?

Question

A 45-year-old man is evaluated for abnormal liver tests. The patient has had no nausea, vomiting, diarrhea, or weight loss. He has no significant medical problems, takes no medications, and has never been hospitalized or received blood transfusions. The patient consumes 1 or 2 beers during the week and, occasionally, 4 to 6 beers on the weekend. He does not smoke cigarettes or use illicit drugs. The patient works in a warehouse and is monogamous with his wife.
Vital signs are within normal limits. BMI is 30 kg/m². There is no scleral icterus, lymphadenopathy, or rash. The abdomen is soft and nontender without hepatosplenomegaly. The remainder of the physical examination shows no abnormalities.
The most recent laboratory results are as follows:

Repeat liver function testing shows similar results.
What is the most appropriate next step in management of this patient?

Quizplus · Accepted Answer

11ec193a_9806_4ccf_853d_515e0349fa37_MD0002_00 This patient has mildly elevated aminotransferases in the setting of minimal alcohol use and an elevated BMI, raising the possibility of nonalcoholic fatty liver disease (NAFLD). The main causes of a hepatocellular pattern of aminotransferase elevation are steatosis/steatohepatitis (either alcohol- or metabolism-related), medications (eg, acetaminophen), hepatitis B and C infection, and hemochromatosis. Although a large portion of patients with viral hepatitis have identifiable risk factors for infection, many patients do not report them. Consequently, to establish the diagnosis of NAFLD, other common causes of liver disease, including viral hepatitides and hemochromatosis, should be excluded as either the primary diagnosis or a concomitant illness. This is especially important, as these diagnoses relate to the reversibility of liver damage and have distinctive management strategies. (Choice A) Although NAFLD may be the most likely diagnosis, it is a diagnosis of exclusion. Diagnosis is based on the demonstration of hepatic steatosis by imaging or biopsy after significant alcohol consumption or other causes of hepatic steatosis have been excluded. Viral hepatitis should be ruled out first, as effective treatment is available. (Choice C) In most cases, noninvasive testing elucidates the cause of isolated increases in aminotransferases. A liver biopsy may be indicated if initial testing does not lead to a definitive diagnosis. (Choice D) This patient's alcohol intake is not excessive (>15-21 drinks/week in men, >10-14 in women). Alanine aminotransferase (ALT) is higher than aspartate aminotransferase (AST), as opposed to an AST/ALT ratio of ≥2, and there is no macrocytosis. Collectively, these factors suggest a nonalcohol-related cause, so recommending reduced alcohol consumption without first evaluating for other causes would be inappropriate. (Choice E) Elevation in aminotransferases can also be seen in nonhepatic disorders such as muscle injury, thyroid disease, adrenal insufficiency, and celiac disease. Testing for these disorders should be done once hepatic causes have been excluded. Educational objective: Consistent, modest elevations in aminotransferases are most commonly due to hepatic steatosis (either alcohol- or metabolism-related), medications, viral hepatitis, or hemochromatosis. Nonalcoholic fatty liver disease is diagnosed by the exclusion of other common liver diseases. __________ References: When and how to evaluate mildly elevated liver enzymes in apparently healthy patients. (http://www.ncbi.nlm.nih.gov/pubmed/20200170)

A 45-Year-Old Man Is Evaluated for Abnormal Liver Tests