Abstract
Purpose: Nonalcoholic fatty liver disease (NAFLD) is 5-10% excessive fat accumulation in liver, as compared to total liver weight in nonalcoholics, which can progress to steatohepatitis (NASH) leading to cirrhosis. We present a case presenting with hemetemesis as an initial manifestation of NAFLD-related cirrhosis. Case: A 58-year-old female with diabetes mellitus and hypertension presented with complaint of 3-4 episodes of hemetemesis with dark clots, mild abdominal pain, and black, tarry stools after hemetemesis and dizziness. She admitted to use of Goody powder 3-4 times a day for the past three years, for arthritis. She denied similar episodes in past. The patient was nonalcoholic, and quit smoking 20 years ago. Her home medication: losartan, lortab, neurontin, glipizide, metformin, and Goody powder. Physical exam: BP 99/48, HR 110, BMI 28.9, unremarkable abdomen exam. Initial lab value: HB 7.0, HCT 22.7, platelet 216, albumin 2.9, AST 32, ALT 24, Alk Phos 220, total bil 0.3, glucose 366, prothrombin time 16.2, Gamma glutamyl transpeptidase 72, HBA1C 7, triglyceride 380. EGD revealed esophageal varices with erosion on one varix, and six bands were placed. She received four units of blood transfusion. Viral hepatitis marker: hepatitis A, B, C and autoimmune marker ANA, AMA, SMA were negative. Ceruloplamin level 38, AFP 2.2, ferritin 32. Ultrasound abdomen showed fatty liver, but no splenomegaly, portal vein, or splenic vein thrombosis. Her presentation was thought to be secondary to NAFLD-related cirrhosis, considering risk factors of diabetes, hyperlipidemia, and hypertension. Liver biopsy showed Mallory's body, regeneration nodules, and sinusoidal fibrosis with macrovesicular fatty changes consistent with cirrhosis. The patient was treated with supportive care, and advised for aggressive risk factor modification. Discussion: Type 2 diabetes mellitus, hyperlipidemia, and obesity are recognized risk factors for NAFLD. NAFLD is now considered a hepatic component of the metabolic syndrome. Variceal bleeding as a first manifestation of NAFLD-Cirrhosis is rare, but associated with high mortality. Patients with variceal bleeding require betablockers and frequent surveillance endoscopy, along with modulating the risk factors, such as weight reduction, glycemic and hyperlipidemic control, and avoiding hepatotoxic agents.Figure
Published Version
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