NON ALCOHOLIC FATTY LIVER DISEASE

A 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)

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)

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

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 NASH (Non Alcoholic Steatohepatitis) that failed to resolve without significant fibrosis.