Q3: Recent PLAB 1 Exam Style Question
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A 38-year-old male presents to the clinic with generalized fatigue and unexplained weight loss. His medical history includes type 2 diabetes mellitus managed with metformin and pioglitazone. He has no history of alcohol consumption and no family history of liver diseases. His BMI is calculated to be 34.
Blood tests reveal the following results:
- HbA1c: 72 mmol/mol
- Fasting Glucose: 9.1 mmol/L
- Ferritin: 160 ng/mL
- Bilirubin: 22 µmol/L
- ALP: 180 U/L
- ALT: 155 U/L
- AST: 125 U/L
- GGT: 75 U/L
What is the SINGLE most likely cause of these abnormal laboratory findings?
A. Hemochromatosis
B. Wilson's Disease
C. Drug-induced liver injury from pioglitazone
D. Non-alcoholic fatty liver disease (NAFLD)
E. Alcoholic liver disease
Answer: D. Non-alcoholic fatty liver disease (NAFLD)
Background:
The patient is a 38-year-old male with type 2 diabetes mellitus, obesity (indicated by a BMI of 34), and abnormal liver function tests. He denies any alcohol consumption.
Interpreting the Results:
- HbA1c of 72 mmol/mol: Poor glycemic control.
- Ferritin of 160 ng/mL: Within the normal range, less likely to be hemochromatosis.
- Elevated ALP, ALT, AST: These liver enzymes are all elevated, pointing towards liver dysfunction.
- GGT: This test is often done to further investigate liver problems. Elevated GGT levels may suggest hepatobiliary disease.
Diagnostic Reasoning:
A. Hemochromatosis: While diabetes and liver dysfunction can occur in hemochromatosis, the normal ferritin level makes it less likely.
B. Wilson's Disease: This is usually diagnosed in younger patients and would likely present with more neurologic and psychiatric symptoms.
C. Drug-induced liver injury from pioglitazone: While drug-induced liver injury is a possibility, it's more common for medications like acetaminophen, and pioglitazone is generally considered to have a low risk for hepatotoxicity.
D. Non-alcoholic fatty liver disease (NAFLD): Given the patient's type 2 diabetes, obesity, and abnormal liver function tests, NAFLD is the most likely diagnosis. This is a common condition that often occurs in individuals with metabolic syndrome.
E. Alcoholic liver disease: The patient denies alcohol use, making this less likely.
Summary:
The most likely diagnosis in this patient is non-alcoholic fatty liver disease (NAFLD), which is common in patients with type 2 diabetes and obesity. NAFLD can lead to liver dysfunction, which is reflected in the abnormal liver function tests. This patient should undergo further investigations like a liver ultrasound and potentially a liver biopsy to confirm the diagnosis and assess the extent of liver damage. Lifestyle changes and diabetes management will also be key components of treatment.
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Reference:
Non-alcoholic fatty liver disease (NAFLD): assessment and management - NICE: This is a guideline from the National Institute for Health and Care Excellence (NICE) that sets out an assessment and management strategy for adults, young people and children with NAFLD. It includes recommendations on identifying people at higher risk of NAFLD, diagnosing NAFLD and advanced liver fibrosis, lifestyle modifications, pharmacological treatment, and monitoring for cirrhosis and extra-hepatic conditions.
Non-alcoholic fatty liver disease (NAFLD) | NHS inform: This is a website from the National Health Service (NHS) that provides general information on NAFLD for the public. It covers the symptoms, causes, diagnosis, treatment, complications and prevention of NAFLD.
NAFLD – diagnosis, assessment and management - The British Society of Gastroenterology: This is an article from the British Society of Gastroenterology that provides an overview of the diagnosis, assessment and management of NAFLD. It covers the epidemiology, pathophysiology, risk factors, clinical presentation, investigations, staging, treatment options, and follow-up of NAFLD.
