Test your medicine knowledge with the MKSAP challenge, in partnership with the American College of Physicians.

A 42-year-old man is evaluated in follow-up for elevated liver chemistry tests. He is asymptomatic. He has a 6-year history of type 2 diabetes mellitus, hyperlipidemia, and hypertension. His current medications are metformin, simvastatin, and lisinopril. He does not drink alcohol.

On physical examination, temperature is 37.0 °C (98.6 °F), blood pressure is 130/74 mm Hg, pulse rate is 82/min, and respiration rate is 14/min. BMI is 32 kg/m². Abdominal examination discloses mild hepatomegaly and active bowel sounds.

Laboratory studies:

Alkaline phosphatase	90 units/L
Alanine aminotransferase	120 units/L
Aspartate aminotransferase	85 units/L
Total bilirubin	1.1 mg/dL (18.8 µmol/L)
LDL cholesterol	100 mg/dL (2.59 mmol/L)
Hemoglobin A1c	7.2%
Iron	75 µg/dL (13 µmol/L)
Total iron-binding capacity	300 µg/dL (54 µmol/L)
Hepatitis B surface antigen	Negative
Antibody to hepatitis B surface antigen	Positive
Hepatitis C virus antibody	Negative

Abdominal ultrasound reveals increased hepatic echotexture consistent with hepatic steatosis. Hepatic configuration is otherwise normal.

In addition to weight loss, which of the following is the most appropriate management?

A: Discontinue simvastatin
B: Initiate entecavir
C: Phlebotomy
D: Serial monitoring of aminotransferases

MKSAP Answer and Critique

The correct answer is D: Serial monitoring of aminotransferases. This item is available to MKSAP 16 subscribers as item 2 in the Gastroenterology and Hepatology section.

MKSAP 16 released Part A on July 31. More information is available online.

The most appropriate management is serial monitoring of aminotransferases, in addition to weight loss through dietary and lifestyle changes. There is no definitive treatment for nonalcoholic fatty liver disease. The reduction of underlying risk factors is essential. Weight loss, exercise, and aggressive control of plasma glucose, lipids, and blood pressure are the mainstays of treatment. Nonalcoholic fatty liver disease has become a leading cause of liver disease in the Western world, along with hepatitis C and alcoholic liver disease. When hepatic steatosis is associated with liver inflammation, as is seen in this patient with elevated hepatic aminotransferases, nonalcoholic steatohepatitis (NASH) is diagnosed. The association of NASH with the metabolic syndrome (obesity, dyslipidemia, hypertension, insulin resistance) is well established. Although most cases of nonalcoholic fatty liver disease are seen in patients who are overweight, the condition has also been described in patients who have a normal BMI. The cornerstone of management of NASH is typically weight loss through diet and lifestyle modification. Monitoring of hepatic aminotransferases is appropriate to confirm that weight loss results in improved markers of liver inflammation. Associated medical conditions such as dyslipidemia should be treated, and statins such as simvastatin should not be discontinued in this setting. The risks of hepatotoxicity due to the use of medications such as simvastatin are usually outweighed by the benefits derived from these medications in regard to cardiovascular risk reduction.

This patient’s hepatitis B serologies indicate immunity to hepatitis B virus; therefore, an antiviral medication such as entecavir is not appropriate.

This patient’s iron stores are not elevated, with a transferrin saturation (iron/total iron binding capacity) of less than 45%; therefore, phlebotomy is not warranted as a treatment in this setting.

Key Point

• Weight loss, exercise, and aggressive control of plasma glucose, lipids, and blood pressure are the mainstays of treatment for nonalcoholic steatohepatitis; monitoring of hepatic aminotransferases is appropriate to confirm that weight loss results in improved markers of liver inflammation.

Learn more about ACP’s MKSAP 16.

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