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

A 68-year-old woman is evaluated for a 3-month history of gradually progressive abdominal distention. Her medical history is notable for a 20-year history of obesity, type 2 diabetes mellitus, hyperlipidemia, and hypertension. She also has had a 10-year history of elevation of serum aminotransferase levels, which was attributed to nonalcoholic fatty liver disease. She does not consume alcohol. Her medications are metformin, lisinopril, low-dose aspirin, and simvastatin.

On physical examination, vital signs are normal; BMI is 38. Spider angiomata are present. Abdominal examination is limited by obesity, but there is mild abdominal distention consistent with ascites. There is no obvious hepatomegaly or splenomegaly.

Laboratory studies:

Platelet count	68,000/µL (68 × 109/L)
Alanine aminotransferase	54 U/L
Aspartate aminotransferase	64 U/L
Albumin	3.2 g/dL (32 g/L)
Total bilirubin	2 mg/dL (34.2 µmol/L)
Direct bilirubin	1.4 mg/dL (24 µmol/L)
Urinalysis	1+ protein

Which of the following is the most appropriate next step in management?

A: Echocardiogram
B: Liver biopsy
C: Stop simvastatin
D: Ultrasound of the liver and spleen

MKSAP Answer and Critique

The correct answer is D: Ultrasound of the liver and spleen.

The most appropriate diagnostic test to perform next is ultrasound of the liver and spleen. This patient has a history of nonalcoholic fatty liver disease (NAFLD) and now has abdominal distention suggestive of ascites. Her low platelet count is suggestive of portal hypertension, and liver dysfunction is supported by the slightly elevated serum bilirubin and low albumin levels.

The next test should be liver imaging with a test such as ultrasound to assess for changes consistent with portal hypertension. In the United States, many cases of “cryptogenic” liver disease are likely related to advanced NAFLD.

Although this patient has risk factors for cardiac disease, she does not have other signs or symptoms suggestive of heart failure. In addition, cardiac dysfunction, unless very long-standing, would not produce splenomegaly. Therefore, echocardiography is not necessary at this time.

Liver biopsy to diagnose cirrhosis is not necessary in patients with other clear manifestations of liver dysfunction and portal hypertension, such as is seen in this patient.

Simvastatin rarely produces mild liver test abnormalities but does not cause chronic liver injury or portal hypertension. Patients with NAFLD have a high prevalence of coronary artery disease; therefore, risk-factor reduction, including the use of statins where appropriate, is advised.

Key Point

• Liver imaging with a test such as ultrasound is useful for assessing changes consistent with portal hypertension.

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