A 59-year-old woman comes to the office due to fatigue and generalized itching that have developed slowly over the last year. She has not had a visible rash. The patient is reluctant to seek health care and has not seen a physician in years. She does not use tobacco, alcohol, or illicit drugs. Vital signs are normal. Examination shows mild hepatomegaly. Laboratory studies show a striking increase in serum alkaline phosphatase, with moderate elevations in bilirubin and hepatic transaminases. Liver biopsy reveals dilated bile canaliculi with green-brown plugs and yellowish-green accumulations of pigment within the hepatic parenchyma. The patient does not return for her scheduled follow-up appointment to discuss further management. This patient is at risk for developing which of the following complications?

Question

A 59-year-old woman comes to the office due to fatigue and generalized itching that have developed slowly over the last year.  She has not had a visible rash.  The patient is reluctant to seek health care and has not seen a physician in years.  She does not use tobacco, alcohol, or illicit drugs.  Vital signs are normal.  Examination shows mild hepatomegaly.  Laboratory studies show a striking increase in serum alkaline phosphatase, with moderate elevations in bilirubin and hepatic transaminases.  Liver biopsy reveals dilated bile canaliculi with green-brown plugs and yellowish-green accumulations of pigment within the hepatic parenchyma.  The patient does not return for her scheduled follow-up appointment to discuss further management.  This patient is at risk for developing which of the following complications?

Quizplus · Accepted Answer

11ec160b_3934_423a_9249_47dcce070349_MD0001_00 This patient has fatigue, pruritus, hepatomegaly, and an elevated alkaline phosphatase level suggesting cholestatic liver disease. Cholestasis can arise secondary to hepatocellular dysfunction or intrahepatic or extrahepatic biliary obstruction. Both obstructive and nonobstructive cholestasis are characterized by the deposition of bile pigment within the hepatic parenchyma, often with green-brown plugs in the dilated bile canaliculi. When it is prolonged, the reduction in bile flow causes intestinal malabsorption of fats and fat-soluble vitamins (A, D, E, and K), which require bile salts for digestion. (Choice A) Cardiac dilation can result from deficiency of thiamine (vitamin B₁), a water-soluble vitamin. Deficiency is common in patients with alcohol use disorder, not cholestatic liver disease. (Choice B) Wilson disease is an autosomal recessive disorder characterized by abnormal biliary handling of copper. Liver disease with eventual cirrhosis is common. Central nervous system involvement can cause dysarthria, ataxia, and movement disorders including chorea and athetosis. Hepatocellular markers (eg, transaminases) will be elevated more prominently than cholestatic markers. (Choices D and E) Atrophic gastritis can be due to autoimmune causes (pernicious anemia), Helicobacter pylori infection, radiation, or granulomatous conditions. Loss of intrinsic factor production by parietal cells can lead to deficiency of vitamin B₁₂ with resulting macrocytic anemia. (Choice F) Seborrheic dermatitis is a common inflammatory condition characterized by accumulation of scaly, greasy skin on the scalp, face, ears, eyelids, and eyebrows. Severe or widespread seborrhea is seen in HIV infection and Parkinson disease, but it is not associated with cholestatic liver disease. Educational objective: Cholestatic liver disease can cause malabsorption and nutritional deficiencies of fat-soluble vitamins.

A 59-Year-Old Woman Comes to the Office Due to Fatigue