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Steatohepatitis(or fatty liver) is indeed associated with an enlarged liver.
Diabetes may be associated with steatohepatitis as diabetes alters the metabolism of fats and cholesterol as well. There is a strong association with steatohepatitis and elevated triglycerides (which are in themselves a combination of fat plus sugars)
Elevated triglycerides over time causes too much fats to be reabsorbed in the GI tract along with bile acids and these are returned to the liver. This over time causes the liver to store too much fat and it does cause enlargement of the liver.
This condition may cause elevation of liver function tests.
If she drinks alcohol this is another possible reason for the condition.
Treatment for steatohepatitis should be based largely on an improved diet. Reduced sugars and low fat diet helps.
There is also benefit from using a certain class of cholesterol, reducing medications which are referred to as bile acid sequestrants. These meds include Welchol, Questran, and Colestipol as examples.These medications work by binding bile acids and fats and eliminating them through the GI tract and reducing their reabsorption by to the liver. Over time this treatment benfits fatty liver.
There are different possible causes of an enlarged liver but I think that fatty liver changes would be more likely at her age. (vascular congestion from congestive heart failure would be another possible cause of an enlarged liver for example but this would seem much less likely at her age for example)
The blood tests are the most common and first line method of evaluating problems of the liver. Imaging studies may complement the picture. In some cases it may be necessary to perfoorm a liver biopsy but this is most often not necessary.
I hope this information helps. If you have further questions then let me know and I wiull be happy to get back with you. If my answer has been helpful and to your satisfaction then please remember to press the "ACCEPT" button. Thank You and Best regards,
Anthony Bray MD
Thank you for your detailed information which was much appreciated. Reference to alcohol my daughter does not drink at all. She also underwent a liver biopsy after 2 ultrasounds and several blood tests. It took approx 12months for the initial diagnosis of steatohepatitis. Due to serious abdominal pain for several months she has learned to cut fat out from her diet almost completely although had always been a healthy eater of daily salads and fruit having been a keen ice skater for 10years and often took part in fun runs. She now works full time as a paediatric nurse on 13hour shifts and is feeling very fatigued.
Thank you for your detailed information it was much appreciated. Reference to alcohol my daughter does not drink. She has always followed a healthy diet and been fairly active. After undergoing 2 ultrasound scans and several blood tests a liver biopsy was carried out and steatohepatitis was mentioned. It seemed to take 12months to reach this diagnosis after irregular blood tests and a couple of hospital admissions following viral infections. We are aware her immunity seems low although was told it was not autoimmune disease. She is now following an almost fat free diet to keep the abdominal pain at bay and is in a nursing career consisting of 13hour shifts which leaves her in a permanent state of tiredness. I obviously get quite concerned for her especially living away from home and can only keep telling her to eat well and take her insulin which I suspect doesn't happen as it should especially whilst working. I believe the condition is reversible but how much can the liver take with all this abnormality?
If she is a type one diabetic on insulin then she has to really watch her intake and insulin. She would be susceptible to both hyperglycemia and hypoglycemia. The diabetes may be related to her increased suspectibilty to infection.
Her diabetes is likely related to her fatigue as well.
I agree that her long shifts may adversely impact how well she may be able to manage her medication and diet.
If bread causes bloating then she might need to be tested for gluten sensitive enteropathy as well.
She should consult her gyn or endocrinologist with regard to her very irregular periods as well.
I hope this helps. Let me know if you have further questions. Best Regards,
The adverse affect with muscle pain /soreness/ or weakness occurs in less than 10% of those whom start on statins. It is the most common reason that this class of medication has to be stopped. In a small percentage it may even cause damage or breakdown of muscle tissue (rhabdomyolosis).
In some people it can cause a rise in liver function tests. This does tend to reduce the production and storage of fats>>cholesterol in the liver and so it may be of benefit with fatty liver disease.
With her experience I would recommend that she try a bile acid sequestrant which binds to fatty bile acids and increases the amount that is excreted through the GI tract. It reduces the amount of fat that is reabsorbed in the GI tract and in this way it tends to lessen the problem of fatty liver (over time...the effect is not immediate) This class of medication includes Welchol, Colestipol and Questran. This class is not subject to the same side effects as the statins and is not related to the statin group. Over time it should improve the fatty liver and improve the liver function tests back toward normal.
She wuld not be expected to have any muscle symptoms with this type of treatment. She should if she is prescribed one of these >> then she should take some vitamin supplements especially of vitamin A, D E and K as these are fat soluble vitamins and their absorption may be decreased by the bile acid sequestrant group.
I hope this information helps. If you have further questions then let me know and I will be happy to get back with you. Best Regards,
I agree with you on the CoQ10. I generally recommend 100mg/day of this if used as a supplement. The statins can deplete this nutrient but her short duration of taking the statin should not have had that much affect on this. Still CoQ10 is related to the cells conversion of sugar to energy. B-complex supplement may also have benefit to her fatigue.
The plenty of water is also sound advise in the event of rhabdomyolosis.
If she continues to have problems then she should have some follow up.
I hope this helps. Further questions are welcome if you have others. Best Regards,
Her fatigue and having trouble staying awake might be due to a separate problem. Fatigue is a common symptom to so many things but also within the symptom of fatigue there are often clues within the details. The sleepiness may reflect fatigue due to hypothyroidism or a sleep disorder (more commonly obstructive sleep apnea or restless leg syndrome) or certain other illnesses such as mononucleosis as some of the prime examples.
I think that rechecking her liver function tests and blood counts, muscle enzyme levels and perhaps full mono related titers(EBV ((Epstein Barr Virus>>titers and not simply a "monospot" test) may be of help. Inflammatory markers(C-reactive protein and sed rate)
may also be of some help.
I hope this helps some. I hope that she improves quickly. Best Regards,
A further liver function test had been carried out and she was told there were no significant changes detrimental to any previous readings but had more tests done whilst at the surgery which could be the muscle enzyme testing? Meanwhile an appointment has come through to attend an Endocrinology Clinic in May. Sorry I may seem vague with some of my details I am dealing with someone who is not always the most forthcoming talker and even monosyllabic on occasions. I try to phone her each day but the nagging mother doesn't always go down too well!
I hope that her further evaluation goes well. Mainly I hope that she improves with regard to how she is doing overall. I'm glad to hear that follow up liver functions were apparently OK.
Take Care and Best Regards,
Reference to my daughter who was diagnosed with steatohepatitis has recently been in hospital with a severe kidney infection with hyperglycaemia and ketoacidosis and whilst during her stay a blood culture showed a growth of e-coli! She has been quite poorly and was severly dehydrated especially after a bout of severe diarrhoea the week previously. She is now back home and after a 10 course of antibiotics she is still feeling tired and not much appetite. After seeing the endocrinolgy specialist last month it was suggested she has glycogen storage disease. I am assuming this is not the same as steatohepatitis? I have tried reading up on GSD but not following it too well apart from realising it is to do with enzymes and synthesis? Are you able to explain it to me and is this why she is not 'picking up' very quickly?
You bring up a complicated class of disorder with glycogen storage disease. There are different subtypes of glycogen storage disease. Glycogen is a chained storage form of sugars.It may be associated with an enlarged liver with liver cells distended with glycogen and fat stored in structures called lipid vacuoles. It may be associated with high triglycerides, cholesterol and phospholipids. Low blood sugar and lactic acidosis would be a risk with certain types.
There are different enzymes which are the basic source of the problem in the different subtypes. Narrowing down the specific subtype will be necessary to completely classify her disease.
That is about all that I can tell you for now as I need to go offline for a while. I will be back later this afternoon.
The infection that she is recovering from may have much to do with her slow recovery but the glycogen storage disease may be a factor in this as well.
I will get back with you later this PM.
Take care for now! Anthony Bray MD
I became hopeful after the diagnosis of steatohepatitis learning that it was reversible over time especially helped by an appropriate diet. Now I'm not too sure whether the glycogen storage disease is reversible? Could it be hereditary? We could not trace a history of diabetes in the family but I do know my daughter's father had a mother that had a stroke at a fairly early age followed by several other strokes and spent many years in hospital. She became blind and paralysed. Unfortunately I have no contact with the fathers side of the family and it must be about 20years ago since his mother passed away. Although it would be difficult would it be worth trying to make some investigations? Understandably part of me doesn't want to know and live in hope my daughter can feel well and live a full life. She is taking herself on holiday next week and tells me she had started to take aspirin without consultation as she is concerned about the flying and blood clots after being on clexine every day whilst in hospital for 6 days. They mentioned her illness and condition had caused her blood to become 'glucky'? but since being discharged no further clexine was mentioned. She just ended up with antibiotics, codene for severe headaches which she doesn't normally have and antisickness tablets. Since finishing the antibiotics last Thursday she has no more headaches which I thought could have been due to the dehydration or antibiotics and the queeziness has also gone. Today she sounded much brighter considering she went back to work yesterday on a 13hour shift! As you will gather she is not easily defeated although has her moments of feeling down just through getting up each day and not feeling as well as she should. There are a few questions in this last response and hope you can give me some positive advice.
There are different types of glycogen storage disease and some are inherited and others may be acquired.
The disorders may be subdivided into groups. One group involves muscle energy impairment.Another group involves mainly the liver and may be associated with enlarged liver and hypoglycemia as complications. A third group involves galactose disorders. A fourth group involves fructose disorders. (There are some overlap of some symptoms between groups such as hypoglycemia or enlargement of the liver within some of the groups other that the second)
I think that type Ia might be her disorder based on what we have discussed. This involves glucose -6 phosphatase deficiency (or translocase deficiency) This type may be associated with growth retardation, enlarged liver and kidney, hypoglycemia (this could be confused if she also had diabetes however), elevated blood lactate, high cholesterol and triglycerides and uric acid. She could be tested for G6PD (glucose 6 phosphatase deficiency) If she had this subtype then she would need some dietary restrictions and directions>> avoidance of fructose and galactose, dietary supplements of calcium and multivitamins. Hyperlipidemia would be likely treated with a cholesterol lowering medicine such as Lipitor or Crestor, Allopurinol might be needed to lower uric acid levels and reduce risk of gout. An ACE inhibitor (blood pressure medicine ) would be helpful to protect the kidneys and a citrate supplement might be needed to help protect against kidney stones. Note that a prolonged fast would need to be avoided as this would induce an acidosis.
The above example is relatively common as compared to some. There may be clues as to her subtype from any health problems during her childhood.
Other subtypes are possible and the type does need to be confirmed with testing. I don't suggest that you pursue any of the treatment steps for the above example without confirmation of the type with further testing. If she has G6PD deficiency then she would also need to let any MD know of the condition as there are some drugs that are contra-indicated with this condition.
Subtypes IX, 0 and XI would also potentially fit her clinical picture and these would be relatively benign in their course as compared to most of the others.
So I think that for now the theory that she may have a glycogen storage disease is just a theory but it does seem to fit with certain aspects of her findings. This theory needs to be confirmed and the subtype needs to be established if she indeed does have one of these. The potential treatment recommendations would vary depending on the subtype and specific enzyme deficiency.
Specifically pertinent to her situation of having diabetes plus a glycogen storage disease is the complicated picture that she may typically have high blood sugars but would be at high risk for abnormal LOW blood sugars if she fasted for a long period of time. (Glycogen is the buffer that is broken down into sugar when the supply runs low) This would also correspond to a lactic acidosis. These aspects would certainly fit. Some types of glycogen storage disease will have more or less effects on her liver, kidneys and muscles. She may have high cholesterol due to one of these glycogen storage diseases.
I hope this information helps. If you should have further questions then let me know and I will be happy to get back with you. If my answer has been helpful and to your satisfaction then please remember to press the "ACCEPT" button. Thank You and Best Regards,