A 48-year-old woman comes to the office after abnormal serum liver chemistry results were found during a life insurance medical evaluation. She has no chronic medical issues and takes no medications. The patient says she has felt excessively tired lately, which she attributes to menopause. She has had no hot flashes, changes in sleep pattern, anorexia, or weight loss. The patient does not use tobacco, alcohol, or illicit drugs. She works in an accounting firm. Her father died at age 62 from an unknown liver disease. Vital signs are within normal limits. BMI is 30 kg/m². She has small bilateral xanthelasmata but no scleral icterus. The thyroid is not enlarged. Cardiopulmonary examination is unremarkable. The abdomen is soft and nontender with no hepatosplenomegaly. She has no skin rash. Current laboratory results are as follows: Abdominal ultrasonography reveals a normal-sized liver and no gallstones. Intrahepatic and common bile ducts are normal. This patient is at greatest risk for which of the following due to nutritional complications of her current condition?

Question

Quizplus · Accepted Answer

Explanation: Metabolic bone disease, such as osteopenia and osteoporosis, is a frequent complication of primary biliary cholangitis (PBC). Its cause is unknown, although its increased prevalence among patients with PBC may in part be due to its predisposition to affect female patients who are frequently postmenopausal and already at risk. As PBC progresses, cholestasis may cause toxic accumulations of substances that inhibit bone turnover. Vitamin D levels are typically normal in these patients, with the exception of those with extremely advanced disease (due to severe protracted cholestasis causing fat malabsorption). Therefore, it is important to screen regularly for osteoporosis (eg, using bone densitometry) in such patients. Calcium and vitamin D supplements are generally recommended, and bisphosphonates (eg, alendronate) are indicated for those with established osteoporosis. Osteomalacia (decreased bone mineralization) can sometimes be seen with PBC and is typically associated with vitamin D deficiency. (Choices A, B, C, and D) In the United States, most water-soluble vitamin (eg, vitamin B) deficiencies are rare and usually seen in patients with chronic alcoholism, severely restrictive diets (eg, anorexia nervosa), or malabsorptive disorders (eg, celiac disease, short gut syndrome). Patients with PBC do not have a significantly increased risk for these deficiencies. Clinical manifestations of select vitamin B deficiencies include the following: Angular cheilosis and stomatitis - nonspecific but can be seen in riboflavin (vitamin B₂) deficiency. Wet Beriberi (eg, dilated cardiomyopathy, polyneuropathy) and Wernicke-Korsakoff syndrome (ie, neurocognitive impairment, oculomotor dysfunction, ataxia, encephalopathy, amnesia) - can be seen with thiamine (vitamin B₁) deficiency. Pellagra (ie, photosensitive dermatitis, diarrhea, dementia) - can be seen with niacin (vitamin B₃) deficiency. Educational objective: Primary biliary cholangitis is associated with an increased risk for osteopenia and osteoporosis, and warrants screening with bone densitometry.

A 48-Year-Old Woman Comes to the Office After Abnormal Serum