A Case of NASH with HYPOTHYROIDISM

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A Case of NASH with HYPOTHYROIDISM

  1. 1. A. KARTHICK RAMALINGAM PROF. P. VIJAYARAGHAVAN’S UNIT
  2. 2.  37 Year old Mrs. Lakshmi was admitted with C/o Abdomen distension - 3 months Abdomen Pain - 3 months HOPI: Patient was apparently normal till 3 months ago after which she developed abdomen distension insidious onset , increasing in size , uniform abdomen distension
  3. 3.  Abdomen distension not associated with Oliguria , pedal edema , facial puffiness, chest pain ,palpitation.  Dyspnoea – insidious onset , progressive , grade II was present.  Abdomen pain – right hypochondrium, dull aching type pain, continuous, aggravated by lying on right side & deep inspiration .
  4. 4.  H/O jaundice -3 months, yellow coloured urine , no clay coloured stools , no pruritis  No LOW  LOA+  No fever, bleeding tendencies, altered sleep  Past H/o Hypothyroid – 8 months—on thyroxine -75 mcg No other co morbid illness
  5. 5.  Personal H/O No Habituations  Menstrual and marital H/O amennorhea-8 months 3 Children  Treatment H/o No H/o chronic drug intake other than thyroxine
  6. 6. General Examination  Conscoius  Oriented  obesity  Afebrile  Icteric  pale  Facial puffiness  Dry skin  Hoarse voice  BP:110/70 mmHg  PR:86/min  JVP not Raised  BMI 26.93kg/sq m
  7. 7.  P/A  uniform distension  Skin normal  Hepatomegaly present 17 cm below right costal margin tender , nodular surface, firm in consistency , no bruit  No splenomegaly.  No Free fluid  Other systems normal
  8. 8. Differential Diagnosis  Infective cause  HCC  Haematological malignancy  Amyloidosis
  9. 9. Investigations CBC Hb 6 gm% TC 9600cells/dl DC P68 L29 E3 ESR 28/60 MCV 79.5 fl MCHC 28.3 RBS 101 mg/dl UREA 22 mg/dl Creatinine 0.7 mg /dl Na 147 K 2.9 HCO3 21 Cl 100 LFT T.Bilirubin 2.5 SGOT 48 SGPT 22 ALP 148 T.Protein 6.5 Globulin 3.2 albumin 3.3 PT 19 sec INR 1.9
  10. 10.  Peripheral smear: Normocytic Normochromic anemia Free T4 0.3 ng/dl TSH 72.5mic IU/ml Urine Alb Nil Sug Nil Dep 0-2 Pus cell/hpf
  11. 11.  USG Abdomen:  Hepatomegaly with fatty infiltration.  Portal Vein 15 mm. normal flow  Splenomegaly 14 cm
  12. 12.  CECT Abdomen  Liver enlarged – 24 cm. Diffusely hypodense area of altered density seen in segment 5/8  GB contracted  Spleen 15 cm enlarged  IMP: Fatty liver with hepatomegaly. Areas of altered density noted in segments 5/8 of right of liver
  13. 13. P.V Doppler  Liver increased in echoes ,enlarged. portal vein 1 cm at the hilum .(Flow +) Portal vein 1.4 cm at the confluence of splenic and SM vein Velocity 18.87 cm/s Hepatopedal flow+ Hepatic veins flow +  Spleen 14.4 cm enlarged . Splenic Vein 17 cm at the hilum  IMPRESSION  Hepatosplenomegaly with Fatty liver
  14. 14.  Blood for QBC – Negative  HBsAg -- Negative  Anti HCV – Negative  HIV I & II – Negative  AFP – not elevated T. Cholesterol 174 mg/dl HDL 32 mg/dl LDL 120 mg/dl VLDL 22 mg/dl TGL 109 mg/dl
  15. 15.  OGD: Lax OGJ . Otherwise normal  ECHO- Normal
  16. 16. NAFLD score  Age, BMI, hyperglycemia, AST/ALT ratio, platelet count, and serum albumin level  Score =0.915  < -1.455: predictor of absence of significant fibrosis (F0-F2 fibrosis)(negative predictive value of 93%) ≤ -1.455 to ≤ 0.675: indeterminate score > 0.675: predictor of presence of significant fibrosis (F3-F4 fibrosis)(positive predictive value of 90% )  Formula :  -1.675 + 0.037 × age (years) + 0.094 × BMI (kg/m2) + 1.13 × IFG/diabetes (yes = 1, no = 0) + 0.99 × AST/ALT ratio – 0.013 × platelet (×109/l) – 0.66 × albumin (g/dl)
  17. 17.  ANA -- Negative  S.Ceruloplasmin 20.5mg/dl(18-35mg/dl)  S . Iron 23.8 mcg/dl(50-150 mcg/dl)  TIBC 283 mcg/dl(300-360mcg/dl)  Ferritin 21.04 ng/dl (50-200mcg/dl)
  18. 18. Final diagnosis  Non alcoholic steatohepatitis  Pre -Obesity  Hypothyroidism  Nutritional anemia
  19. 19. Treatment given  Thyroxine dose increased to 125 mcg/day  T.vitamin E 400mg twice a day  FST 100 mg twice a day
  20. 20. At discharge CBC Hb 11.8 gm% TC 8000 DC P80 L20 ESR 4/10 Platelet 2.5 lakh TSH 39.98mIU/ml Patient is now on thyroxine 150 mcg/day
  21. 21. DISCUSSION  NAFLD a) There is evidence of hepatic steatosis , either by imaging or by histology. b)There is no causes for secondary hepatic fat accumulation such as alcohol consumption , use of steatogenic drugs or hereditary disorders.
  22. 22.  NAFL The presence of hepatic steatosis with no evidence of hepatocellular injury in the form of ballooning of the hepatocytes  NASH The presence of hepatic steatosis and inflammation with hepatocyte injury(ballooning) with or without fibrosis
  23. 23.  Prevalence :  NAFLD 6.3 to 33%(median -20%)  NASH 3 to 5 %  High risk groups  Type 2 Diabetes Mellitus  Obesity  Dyslipedemia  Metabolic syndrome
  24. 24. Emerging Risk factors  PCOD  Hypothyroidism  Obstructive sleep apnea  Hypopituitarism  Hypogonadism  Pancreatoduodenal resection
  25. 25. What is significant alcohol consumption for eligibility for NASH in clinical practice  >21 drinks per week in men  >14 drinks per week in women over a period of 2 years before baseline histology
  26. 26. When to evaluate incidentally discovered hepatic steatosis  Unsuspected hepatic steatosis detected on imaging have symptoms or signs attributable to liver disease or have abnormal liver biochemistries – should be evaluated as for NAFLD
  27. 27. Screening for high risk groups ?  Not recommended
  28. 28. Non invasive methods to assess steatohepatitis  S.Aminotransferase, USG ,CT,MR donot reliably assess steatohepatitis and fibrosis in patients with NAFLD.  Liver biopsy is the most reliable approach  Non invaisve approaches include a) NAFLD fibrosis score b)Enhanced fibrosis score c)Transient elastography
  29. 29. When to do biposy ?  Those who are increased risk to have steatohepaitis and advanced fibrosis. ( NAFLD score , metabolic syndrome can be used to predict risk)  Competing etiologies for hepatic steatosis and co existing chronic liver disease cannot be excluded without a liver biopsy
  30. 30. Management  Loss of 3 to 5 % weight loss improves steatosis ,loss of 5 to 10 % improves necroinflammtion  Metformin is not recommended as a specific treatment for liver disease in adults with NASH
  31. 31.  Vitamin E 800IU/day improves liver histology in biopsy proven NASH. Considered as first line therapy in this population  Statins should not be used specifically to treat NASH. Can be used in dyslipedemia.  UDCA is not recommended
  32. 32. Hypothyroidism and NASH  Journal of Clinical Gastroenterology:  October 2003 - Volume 37 - Issue 4 - pp 340-343  Liver, Pancreas, and Biliary Tract: Clinical Research Is Hypothyroidism a Risk Factor for Non-Alcoholic Steatohepatitis?  Liangpunsakul, Suthat MD; Chalasani, Naga MD  Abstract  Purpose: Thyroid hormones play an important role in the regulation of lipid and carbohydrate metabolism, both of which are affected in patients with non- alcoholic steatohepatitis (NASH). Anecdotally, we have observed that a number of patients with NASH carried a diagnosis of hypothyroidism. However, it is unknown if thyroid dysfunction plays any role in the pathogenesis of NASH. To further investigate this observation, we conducted a case-control study to determine the association between hypothyroidism and NASH  Conclusion: These data suggest that hypothyroidism is associated with human NASH. Further research is needed to confirm this finding and to understand its implications.
  33. 33.  Dig Dis Sci. 2012 Feb;57(2):528-34. doi: 10.1007/s10620-011-2006-2. Epub 2011 Dec 20.  Prevalence of hypothyroidism in nonalcoholic fatty liver disease.  Pagadala MR, Zein CO, Dasarathy S, Yerian LM, Lopez R, McCullough AJ.  Source  Department of Gastroenterology and Hepatology, Cleveland Clinic Foundation, Cleveland, OH, USA.  Abstract  BACKGROUND:  A possible association between nonalcoholic fatty liver disease (NAFLD) and hypothyroidism has been suggested. The recognized link between hypothyroidism and elements of the metabolic syndrome may explain this association.  AIM:  The purpose of this study was to determine the prevalence of hypothyroidism in a cohort of patients with NAFLD and analyze the potential factors associated with hypothyroidism in this patient population.  CONCLUSIONS:  A higher prevalence of hypothyroidism was demonstrated in patients with NAFLD compared to controls. Among subjects with NALFD, female gender, increased BMI and history of abstinence from alcohol were associated with hypothyroidism. Patients with hypothyroidism were also more likely to have NASH Hypothyroidism and NASH
  34. 34. Hypothyroidism and anaemia  Anaemia is seen in 1/3 to ½ patients with hypothyroidism  Usually mild to moderate , lower levels do occur  Anaemia can be microcytic , normocytic , macrocytic. Aneamia of chronic disease is the most common(normocytc normochromic) .  Microcytosis occurs in the setting of mennorhagia  Macrocytosis can be seen even without anaemia . Overt macrocytosis suggest perinicious anaemia or folate deficiency
  35. 35. Thank you

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