A 33-year-old woman comes to the office due to fatigue over the last 6 months. She attributes this to her stressful work environment but still wants to be "checked up." The patient has no significant medical history, and her only medication is an oral contraceptive. She has had no abdominal pain, back pain, vomiting, diarrhea, or leg swelling. The patient drinks 1 or 2 glasses of wine on most days of the week but does not use tobacco or illicit drugs. Vital signs are normal. Today, her weight is 64 kg (141 lbs), and the patient reports she weighed 68 kg (150 lbs) 3 months ago. The liver edge is palpable 2 cm below the right costal margin. Laboratory results are as follows: Abdominal ultrasound confirms mild hepatomegaly; the pancreas is not well visualized. Chest x-ray reveals bilateral hilar fullness but no parenchymal opacities. Which of the following is the most likely cause of the abnormal liver function studies in this patient?

Question

A 33-year-old woman comes to the office due to fatigue over the last 6 months.  She attributes this to her stressful work environment but still wants to be "checked up."  The patient has no significant medical history, and her only medication is an oral contraceptive.  She has had no abdominal pain, back pain, vomiting, diarrhea, or leg swelling.  The patient drinks 1 or 2 glasses of wine on most days of the week but does not use tobacco or illicit drugs.  Vital signs are normal.  Today, her weight is 64 kg (141 lbs), and the patient reports she weighed 68 kg (150 lbs) 3 months ago.  The liver edge is palpable 2 cm below the right costal margin.  Laboratory results are as follows:  Abdominal ultrasound confirms mild hepatomegaly; the pancreas is not well visualized.  Chest x-ray reveals bilateral hilar fullness but no parenchymal opacities.  Which of the following is the most likely cause of the abnormal liver function studies in this patient?

Quizplus · Accepted Answer

Explanation: This patient has an enlarged liver with elevations of alkaline phosphatase and gamma-glutamyl transpeptidase (suggesting liver rather than bone origin of the alkaline phosphatase elevation); her other hepatic markers are essentially normal. This pattern can be seen with infiltrative liver diseases. The patient also has mild hypercalcemia and signs of hilar adenopathy on chest x-ray. Together, these findings are consistent with hepatic sarcoidosis. Liver involvement occurs in 50%-65% of patients with sarcoidosis, although most are asymptomatic or have nonspecific symptoms (eg, weight loss). More severe disease can lead to jaundice, abdominal pain, cirrhosis, and manifestations of portal hypertension. Liver involvement in sarcoidosis is characterized by infiltration with noncaseating granulomas. The lesions are visible on CT scan and MRI, but biopsy is recommended to rule out other granulomatous diseases (eg, tuberculosis) and metastatic malignancy. Initial treatment of symptomatic hepatic sarcoidosis is with systemic glucocorticoids (eg, prednisone). (Choices A and C) Alcoholic liver disease and hepatic steatosis typically display a hepatocellular injury pattern (ie, elevations in transaminases > elevation in alkaline phosphatase). This patient's moderate alcohol intake is unlikely to lead to significant hepatic injury, and steatosis is often identifiable by increased hepatic echogenicity on ultrasound. Furthermore, this patient's hypercalcemia and x-ray findings are more consistent with sarcoidosis. (Choice D) Older formulations of oral contraceptives were associated with a significant risk of hepatic injury, but risk with contemporary contraceptives is low. When contraceptive-induced cholestatic liver disease does occur, bilirubin is typically elevated. (Choice E) Although hepatomegaly with elevated alkaline phosphatase can be seen with pancreatic cancer, this patient has no risk factors for pancreatic cancer (eg, smoking, obesity, chronic pancreatitis) and is relatively young. In addition, many patients with symptomatic pancreatic cancer have jaundice and abdominal pain, mass lesions are usually visible on ultrasound, and bilirubin is commonly (although not always) elevated. Educational objective: An isolated elevation of alkaline phosphatase can be seen in infiltrative liver diseases (eg, granulomatous disease, infection, certain medications). Additional evidence of granulomatous disease, such as bilateral hilar adenopathy in sarcoidosis, may be helpful in making the diagnosis. References: Clinical presentation and protocol for management of hepatic sarcoidosis. (http://www.ncbi.nlm.nih.gov/pubmed/25473783) Hepatic sarcoidosis. (http://www.ncbi.nlm.nih.gov/pubmed/26357609)

A 33-Year-Old Woman Comes to the Office Due to Fatigue