Case Presentation

34 yrs old male Security officer From Manikhinna

Presenting complaints

Fatigue, malaise Epigastric fullness, dyspeptic symptoms Darkening of skin

8 months

4 month

History of presenting complaints

8 month ago developed fever vomiting &abdominal pain, admitted to hospital,diagnosed as viral hepatitis Symptoms gradually improved But continue to feel fatigue, malaise Feel tired on exertion Had never became jaundice, developed on/off episodes of itching

History cont..

Abdominal pain & discomfort epigastric pain with dyspeptic symptoms, aggravate with meal , no particular radiation or other aggravating /relieving factors Progressive darkening of skin for the last 4-5 months he has noted increased pigmentation of skin , generalized, not in skin creases or scars No H/O jaundice, skin rashes , arthritis or fever

History cont..

No recurrent diarrhea or bleeding PR or altered bowel habits No dry mouth, eye or sicca syndrome No H/O wheezing attacks, haemoptysis No history of, orthopnoea, exertional chest pain or dyspnoea No legs or body swelling

Past medical history/ Drugs

No DM , inflammatory bowel disease, Rheumatoid arthritis , Movement disorders or psychiatric illness Not on drugs, Aurvedic Rx No exposure to Organo-phosphates or organic compounds Had T. Toxoid 1 1/2 yrs ago No H/O blood transfusion

Family / Social history

No cirrhosis , Psychiatric illness , Movement disorders or haematological disease No sexual promiscuity Unmarried security officer, 6000/= Non alcoholic, non smoker

General examination

Not pale, not icteric, not emaciated generalized pigmentation, not in skin creases or scars No chronic liver stigmata's or scratch marks No tendon or palmar xanthomas Has considerable amount of acne No finger clubbing, lymhpadinpathy, oral or genital ulcers

System examination

ABDOMAN 1cm smooth , non tender hepatomegaly. No splenomegaly or free fluid or mass CVS BP- 130/80mmHg, Clinically normal All other systems clinically normal

summery

34 yrs old male, presented with 8month H/O malaise, fatigue,epigastric pain & dyspeptic symptoms,progressive darkening of skin with preceding H/O hepatitis Not pale or icteric, no evidence of liver stigmata's 1cm hepatomegaly,no splenomegaly, free fluid or mass Other systems clinically normal

Causes for chronically elevated AST/ALT

Hepatic Alcohol abuse Chronic Heb B/ C----HepBsAg/ C Ab NAFLD( NASH ) Autoimmunne hepatitis-young ,female----- S. Electroph: --^ polyclonal emmunoglobulin-- 80% Haemochromatosis-- TS >45% Wilsons -- ( <40yrs ) -S. ceruloplasmin -- 85% Alpha1 antitrypsin deficiency -S. electrophoresis-- marked reduction alpha globulin -- Phenotype ZZ

Cont..

NON HEPATIC Celiac sprue-- Anti endomyosial Ab, Antigliadin Muscle disorders -- CPK / Aldolase Strenuous Exercise

Inv.

SGOT-- >60 U/L -------------- 82 SGPT ---> 60 U/L --------------- 170 S. bilirubin 10umol/l ---------- <17 um/l Alk Phos 132 U/L ^-------------123U/L Gama GT -----------------------141 U/L ^ ( 11 - 50 ) PTT 13sec/ 12 sec ESR ----- 47mm/hr S. Protien T-8.5mg/dl Al- 4.4 HepB sAg / Hep C -- neg USS Abdomen mild hepatomegaly with normal echo pattern Rheumatoid factor ----------- Neg

Inv cont..

S. Fe 116umol/l ( N ) TIBC 320umol/l ( N ) S. Ferritin 322ng/ml ( N ) ANF ----------------------- neg Anti-smooth muscles Ab -- neg S electrophoresis --- normal S. Ceruloplasmin 25ng dl ( N ) KF rings -- neg Lipids-- TG 189 ( 157 ) Liver Bx periportal fibrosis with septa formation & mononeuclear cell infiltration. Extensive fatty changers & focal necrosis of parenchymal cells Bile duct proliferation not seen

Non Alcoholic Fatty Liver Disease

Increasingly recognized condition may progresses to end stage liver disease Diabetic hepatitis, NASH, Fatty liver hepatitis Steatosis==> Steatohepatitis ==> Cirrhosis 10 -24 % general population The most common cause of abnormal LFT in adult Cryptogenic cirrhosis share many clinical, demographical features of NAFLD

Risk Factors

Obesity ( truncal ) 10 - 100% DM type 2 10 - 75 % Hyperlidemia ( TG ) 20 -92 % Family H/O NAFLD or cryptigenic cirrhosis Middle age women , some says male

Pathogenesis

Poorly understood, hypothetical Net retention of lipids in hepatocytes prerequisite for NAFLD synthesis *Degradation Secretion Insulin resistance is the most reproducible factor Enzyme deficiency of beta oxidation & Acytyl-coenzyme A important cause of microvesicular steatosisi

Clinical Presentation

Mostly asymptomatic at diagnosis Fatigue, malaise, fullness of abdomen Symptoms & signs of advance liver disease Only physical finding may hepatomegaly, acanthosis nigricance

Diagnosis

Suspect== increased AST/ALT, Radiological fatty liver & persistent hepatomegaly Should exclude alcohol abuse, secondary causes Histologicaly--- Liver Bx
steatosis,monocytes, neutrophils, ballooning necrosis, Mallorys bodies portal tracts relatively spared in some cirrhotic, steatosis & necroinflammation may be not seen

Laboratory investigation

AST to ALT -- <1 Alk Phosp & gama GT -- may elevated but less than alcoholic hepatitis Increased PTT, Bilirubin, reduced Alb -advance liver disease S. Ferritin increased in 50 % Increased Transferin saturation in 11% Hepatic Fe index -- normal

Investigation Cont..

USS increased diffused echogenasity similar to cirrhosis sensitivity - 89% specificity - 93% CT low density hepatic paranchyma fatty sparing focal fatty infiltration -- mimic focal mass

Natural history

Not well defined 28% progressive liver damage in 311yrs 58 % no change 13 % improves or completely resolved

Management

Good control of DM , Hyperlipaedemia Reduction of Wt Drugs No place small pilot studies-- gemfibrozil, Vit E, Metformin, Ursodiol improves LFT Liver transplant--- in end stage liver disease, but may recur

Bad prognosis

Age-- > 45 yrs Obese DM- type 2 AST/ ALT ratio > 1 -- indicate advance fibrosis Increased TG Liver Bx == Steotohepatitis or advance fibrosis