Today we'll talk even further about
disorders of the liver and biliary system
specifically about metabolic liver disease,
Wilson disease and hemochromatosis.
So let's start with a case.
A 68-year-old man is seen in clinic
for follow-up of abnormal liver test.
He has a past medical history of type
2 diabetes, hypertension and obesity.
He takes metformin and lisinopril.
He has 1 to 2 glasses of wine daily but
does not smoke or use illicit drugs.
Vitals are normal,
his BMI is 40.
Physical exam is notable for hepatomegaly
but no jaundice or spider angiomata.
There is no ascites or edema.
Labs are notable for an
ALT of 80 (U/L), AST 59 (U/L)
but albumin, INR, bilirubin, CBC
and iron studies are all normal.
A liver ultrasound shows
an enlarged fatty liver.
So what is the recommended
treatment for his condition?
Let's first go into some
key details in this case.
He has multiple metabolic disorders with his
hypertension, type 2 diabetes and obesity.
On exam, he has both obesity,
hepatomegaly and no signs of cirrhosis.
His labs show a mild
elevation in the AST and ALT.
And his imaging shows fatty liver.
So at this point, you may be considering some
things in his history such as his alcohol use.
However, he has 1 to 2 glasses of wine
daily, so this is not heavy alcohol use
so he'd most likely does not
have alcoholic liver disease.
You might also consider a condition such
as hemochromatosis on your differential
but his iron studies are normal, so
this makes that diagnosis pretty unlikely.
So before we go on to
the answer for this question,
let's talk a bit about
metabolic liver disease.
So metabolic liver disease is the most
common cause of abnormal liver tests
that you will find in western
It has a spectrum of disease ranging from nonalcoholic
fatty liver disease or we refer to as NAFLD
or nonalcoholic steatohepatitis which we refer
to as NASH when inflammation is now present.
So, unsurprisingly, many of the
risk factors for NAFLD or NASH,
depend on metabolic syndromes.
So, any metabolic syndrome,
insulin resistance or type 2 diabetes and obesity
are all common risk factors for these diseases.
This disease is often found incidentally on liver
tests just with mild elevation in the transaminases.
However, it can also progress to cirrhosis
and eventually, hepatocellular carcinoma.
So, we go first from healthy
hepatocytes to eventually,
bloated hepatocytes with fatty
liver infiltration, so this is NAFLD.
And then eventually, you may develop inflammation
and death of hepatocytes which is now NASH.
Both of these conditions are reversible if
you treat and target the underlying factors.
However, once it has progressed
to cirrhosis or scarring of the liver,
you now have irreversible injury.
So the diagnosis used to
be made with liver biopsy.
However, since that is such an invasive test, now
we know that presumptive diagnosis can be made
by looking at risk factors
for NAFLD and NASH,
evidence of fatty liver or
hepatic steatosis on imaging
and having mildly elevated transaminases.
The treatment consist of
controlling the underlying risk factors.
So in most cases, you can
counsel patients on weight loss
and this can also
reverse their liver injury.
So now, we go back to our case.
A 68-year-old man who has multiple metabolic disorders, a mild
elevation in his transaminases and fatty liver on imaging.
Notably, we now know he has no heavy alcohol use and his
normal iron studies make hemochromatosis pretty unlikely.
So, his most likely condition is metabolic
liver disease or NAFLD or NASH.
The recommended treatment for his
condition is recommending weight loss
and control of his
hypertension and diabetes.