Reviewer: S. Randhawa, M.D.
A 64-year-old African American female (AAF) with a past medical history (PMH) of coronary artery disease (CAD), hypertension (HTN), hypercholesterolemia, GERD, diverticulosis is admitted to the hospital with chest pain (CP). She was "ruled out" for acute ischemia and has no complaints now.
Enalapril (Vasotec), tramadol (Ultram), simvastatin, aspirin (ASA), amlodipine (Norvasc).
Social history (SH)
No EtOH or tobacco abuse.
Obese in NAD. BP 187/86.
Elevated lifer function tests (LFTs), mainly AST, ALT and AP (alkaline phosphatase); bilirubin was normal (click to enlarge the image).
What is the first question to ask?
What are the baseline LFTs?
She had normal LFTs one year ago.
What do you think is the reason for elevated LFT?
Hepatitis - viral vs. drug-induced?
What to do next?
Repeat LFTs, check "hepatitis profile", liver U/S.
The hepatitis profile was negative.
U/S of the liver showed gallstones without evidence of cholecystitis and a fatty liver (click to enlarge the image).
How is the lipid profile?
She had elevated triglecyrides and cholesterol.
Fatty liver with likely NASH.
Her LFTs decreased but did not go down to baseline during this hospital stay. She was asymptomatic and was discharged home with a diet modification and a 2-week follow-up.
What did we learn from this case?
Not all elevations of LFTs are due to viral or drug-induced hepatitis. Keep NASH in mind, especially in obese patients with elevated triglycerides or/and cholesterol.
The prevalence of non-alcoholic fatty liver disease with and without increased levels of liver enzymes in the U.S. population was 3.1% and 16.4%, respectively (BMJ, 2011).
Diagnosis and Management of Nonalcoholic Steatohepatitis (NASH). AFP, 2001.
Nonalcoholic Fatty Liver Disease. Now@NEJM blog, 2010.