NAFLD,Non Alcoholic Fatty Liver DiseaseA typical case of NAFLD,Non Alcoholic Fatty Liver Disease. This involves a 55 years old women who is known diabetic from last 8 years and known hypertensive for last 6 years admitted in female medical ward through emergency on 15/1/2015 with following chief complaints

    • Abdominal distention——–12 days
    • Constipation ——————2 days
    • Vomiting ———————–1 day

Patient was in her usual state of health when 12 days back she noticed that her abdomen has swollen and distended. The distention was gradual in onset and but for past 12 days her abdomen became markedly distended there was associated discomfort and mild pain. She was also experiencing shortness of breath with it and mild dry cough.

    • She was also giving history of hard pallet like stools, pale in color, no blood in it
    • Vomitus contain food material , a glass in quantity, 2-3 episodes per day associated with nausea, heart burn, and dyspepsia.
    • Past medical history was un remarkable except that she had diabetes for last 8 years and was using oral hypoglycemic(dimicron MR 60 one OD) but patient was not complaint to the medication. She was hypertensive for last 6 year and using antihypertensive drugs(co-valtec 50/12.5 one OD). There was no past history of hospital admission, no known allergies.
    • She is married for last 25 yrs. having 6 children , 2 male and 4 female. Three of the daughters and the two sons are married. Sons are laborer by profession.
    • Her sleep is good but for past 5 days her food intake is markedly reduced. There is no history of alcohol intake , cigarette smoking or any other addiction.
    • Family history was unremarkable for DM, HTN, IHD, Asthma, TB contact, hepatitis, CVA.
    • Socioeconomic status is poor living in mud house joint family system having 4 rooms and approx. 10+ members.

 

  • On Examination for NON ALCOHOLIC FATTY LIVER DISEASE SYMPTOMS AND SIGNS

General Physical Examination

  • BP   160/90
  • PULSE  81/min
  • Respiratory Rate  20/min
  • Temperature  98.6 F
  • Height  151 cm
  • weight   110 kg
  • BMI    48 kg/m2
  • Pale complexion, jaundice and bilateral pedal edema was present. No other findings on GPE

 

       Systemic Examination

  • On inspection there was largely distended abdomen with everted umbilicus signifying massive ascites with positive fluid thrill
  • Liver, spleen kidney was not palpable, on percussion there was dull notes and on auscultation bowl sounds were reduced.
  • Systemic examination was other wise normal, no other stigmata of liver cirrhosis was present.

 

LABORATORY INVESTIGATIONS

 

  • HB            9.6
  • Na            134
  • TLC           59000
  • K              4.59
  • PLT           57000
  •  Cl             104
  • RBS          253
  • HbsAg    NEGATIVE      by ELISA
  • urea        16
  • HCV        NEGATIVE      by ELISA
  • S.Cret       0.69
  • S. Bil         2.62
  • ALT            37
  • Albumin   2.14

 

  • Serum Cholesterol             300mg/dl      (<200mg/dl)
  • Serum Triglycerides           450mg/dl      (<150mg/dl)
  • LDL                                  190mg/dl       (<190mg/dl)
  • HDL                                  30mg/dl         (> 50mg/dl)

 

  • 3 L of fluid was tapped initially in single session and with that diagnostic tap fluid R/E (Routine Examination) showed a transudative picture
  • Ultrasound abdomen report was consistent with liver cirrhosis and massive ascites

With above data patient was diagnosed as non B non C  DCLD (Decompensated Chronic Liver Disease) patient. The cause of the CLD was not established yet.

Typical TREATMENT CHART in such a patient

 

  • Tab bevidox 1*OD containing vitamin B 1 , B 6 , B 12
  • LVP (Large Volume Paracentesis) under hemacel
  • Tab Ranulcid (ranitidine) 150mg 1*BD
  • Tab pelton-v  (Domeperidone)  1*TDS
  • Tab dimaicron (Gliclizide) MR 60mg  1*OD
  • Tab spiromide (Spironoloctone and furosemide) 1*OD
  • Tab vadil (Carvedilol) 3.125mg 1*BD

 

Further work up showed

  • ANAs      -ve
  • SMA       -ve
  • LKM-1    -ve
  • Serum ferritin    40 ng/ml      (12-150 ng/ml)
  •  Absent kayser-Fleischer rings
  • Ceruloplasmin   30 mg/dl        (20-40 mg/dl)

Sedentary life style, high BMI, type two diabetes and hypertension fit the criteria for metabolic syndrome and the suggested NAFLD. The most likely cause for the DCLD (Decompensated Chronic Liver Disease) was a result of the NASH (Non Alcoholic Steatohepatitis) that failed to resolve without significant fibrosis.