"33 yo woman with incidental right sided abdomenal discomfort"
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"33 yo woman with incidental right sided abdomenal discomfort". James M Sosman, MD. Case History. ID AG is a 35 yo W woman who presents for routine evaluation CC: right sided abdomenal discomfort - PowerPoint PPT PresentationTRANSCRIPT
"33 yo woman with incidental right sided abdomenal
discomfort"
James M Sosman, MD
Case History
ID AG is a 35 yo W woman who presents for routine evaluation
CC: right sided abdomenal discomfort
HPI: AG states that she has noted discomfort for the past few months. Pain is dull and non-radiating over the right lateral side of the chest and abdomen. She states the intensity is 4-5/10. It is aggravated in some positions but is not pleuritic and is not associated with food or exercise. The discomfort is worsened with palpation over that region.
Case History
ROS— She denies fevers, chills, nausea or vomiting,
anorexia, weight loss, jaundice, arthralgias, myalgias, rash, pruritus, and changes in her urine or stool. She also denies recent travel or any “sick” exposures
PAST MEDICAL HISTORY: — Anemia — G0P0AB0
Case History
MEDICATIONS:— MVI 1 a day — Ginseng once a day
NKAD FMHx
— No Hx of GI cancers or gallstones — 60 yo Father with CAD and mild
Diabetes
Case History
SOCIAL HISTORY: — Smokes ½ ppd — occasional alcohol use — Married — works as a manicurist — Denies IDU— She walks 2 miles/day for exercise
Case
PHYSICAL EXAM: — Vitals: BP 139/75, HR 91, RR 16, Temp 96.8 F
Weight 240lbs BMI 38— HEENT WNL— Cardiac and Pulmonary exam WNL— Abdomen- Normoactive BS, no HSM/Mass,
mild discomfort RUQ and Rt lateral Abdomen with no rebound or guarding
— No LNs— Skin WNL other than a 2 yr old butterfly tattoo
on her left shoulder
Diagnostic Options?
Case
Ordered a few lab tests Advised AG to try Ranitidine 150mg
PO BID RTC in 3-4 wks or PRN
Case
Laboratory Studies: — WBC 10.3, Hemoglobin 12.2, PLT 215.
normal differential — Sodium 137, potassium 4.5, chloride
101, CO2 27, BUN 16, Cr 1.1, glucose 110
— T Bil. 0.9, Alk phos 136, AST 45, ALT 75— Urine Pregnancy- neg
What Next?
Abdomenal Ultrasound
Differential Diagnosis of Chronically Elevated
ALT?
Differential Diagnosis of Chronically ElevatedALT
NAFLD — Metabolic syndrome
Alcoholic liver disease Hepatitis C
— IVDU, blood transfusions
Medications — Exposure history
Hepatitis B — Endemic area, IVDU,
MSM Hemochromatosis
— Family history Autoimmune hepatitis
— Family history Alpha-1 AT deficiency
— Family history Wilson’s disease
— Family history
Nonalcoholic Fatty Liver Disease (NAFLD)
A spectrum of disease predominantly characterized by macrovesicular steatosis of the liver that occurs despite little or no consumption of alcohol — Range of disorders from hepatic steatosis, which is
generally benign, to nonalcoholic steatohepatitis (NASH), which may progress to cirrhosis and its complications
Early studies used a strict cutoff of either no alcohol consumption or < 20 g of alcohol intake per week to classify as nonalcoholic etiology
NAFLD represents the hepatic manifestation of the metabolic syndrome
Metabolic Syndrome
Characteristics include:— obesity, hypertension, diabetes,
hypertriglyceridemia, and a low HDL level Approximately 47 million in the US have
metabolic syndrome— > 80% have NAFLD — > 90% with NAFLD have some features of
metabolic syndrome Insulin resistance is the fundamental
pathophysiologic abnormality that connects NAFLD with metabolic syndrome
Classification of Nonalcoholic Fatty Liver
NAFLD: Epidemiology
Approx 33% of the US population has hepatic steatosis — Prevalence
Hispanics 45% Blacks 24%
In an autopsy series, hepatic steatosis in 2.7% of lean individuals and 18.5% of obese individuals
Studies published before 1990 emphasized that NASH occurred mostly in women (53% to 85% of all patients)— In more recent studies NASH occurs with equal frequency
in males
Relationship between BMI, waist circumference, and the presence of
NAFLD
NAFLD is directly related to BMI: More than 80% of individuals with a BMI > 35 have steatosis
Waist circumference may be an even better predictor of underlying insulin resistance and NAFLD than BMI
Common Symptoms Among Individuals With NAFLD
Laboratory Abnormalities
7.9% of the US has persistently abnormal liver enzymes despite negative tests for viral hepatitis and other common causes of liver diseases — related to BMI and other risk factors associated
with NAFLD Elevated ALT level (1-2 fold increase) most
common liver enzyme abnormality— elevation is usually modest (rarely > 300 IU/L) — AST-to-ALT ratio is typically < 1
Natural History of NAFLD Most studies are cross-sectional with highly
selected patient populations Increased risk of cardiovascular mortality Was initially believed that NAFLD rarely
progressed to more advanced liver disease— Steatosis may progress to more advanced liver
disease in < 5% NASH, however, can progress to cirrhosis
— In a study of 103 individuals with NASH who had multiple liver biopsies taken over a median duration of 3.2 years, 37% showed fibrosis progression and 29% showed regression
— Risk of NASH progression to cirrhosis is 20%
Natural History of NAFLD
Pathophysiology of NAFLD
Evaluation
Most of the time NAFLD is identified incidentally— 45-80% of patients are asymptomatic— Patient may have an abnormal ALT— Persistent hepatomegaly without an
obvious cause — abdominal imaging performed for
unrelated reasons reveals a fatty liver
Evaluation: Noninvasive methods for the diagnosis of NAFLD
Hepatic Ultrasound— increased hepatic parenchymal echotexture and vascular blurring — sensitive (85% to 95%) — 62% positive predictive value
Hepatic CT Scan— Hepatic steatosis decreases CT attenuation of the liver (10 or
more Hounsfield units lower than the spleen on a noncontrast-enhanced scan)
— 76% positive predictive value
None of these methods can diagnose steatohepatitis or accurately assess the stage of the disease
How to Evaluate an Individual for the Presence of NAFLD
Exclude alternative causes Assess for features of metabolic
syndrome Non diagnostic imaging (US) Consider assessing for presence of
steatohepatitis (Liver Biopsy)
Conditions and Factors Associated With NAFLD
Metabolic Syndrome Drugs (amiodarone, tamoxifen,
antiretroviral meds) Wilson’s Disease Jejuno-ilealbypass surgery TPN
Drugs Used for the Treatment of NASH
Case AG was told of her presumptive diagnosis
(NAFLD) She was informed to avoid potential
hepatotoxins AG was referred to a dietician and started
on an aggressive exercise program AG will try to stop smoking She will follow up with me in about 2
months to assess progress and obtain fasting lipids