American College of Physicians: Internal Medicine — Doctors for Adults ®

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The MKSAP Challenge

From the January-February ACP Observer, copyright © 2006 by the American College of Physicians.

Clinical scenario

A 44-year-old woman with a 10-year history of type 2 diabetes mellitus and hyperlipidemia is evaluated because of intermittent right upper quadrant abdominal discomfort and newly detected abnormal liver chemistry test results. Her only medication is glyburide, which she has taken for eight years. She does not drink alcoholic beverages.

Physical examination is remarkable only for overweight; she has a body mass index of 29. There are no stigmata of chronic liver disease.

Her laboratory results are:

  • hemoglobin, 13.3 g/dL
  • serum aspartate aminotransferase, 98 U/L
  • serum alanine aminotransferase, 81 U/L
  • serum total bilirubin, 0.4 mg/dL
  • serum albumin, 3.9 g/dL
  • hemoglobin A1C, 9.1%
  • serum iron studies, normal
  • serologic studies for hepatitis A, B, and C, negative
  • antinuclear antibody titer, negative
  • serum alpha1-antitrypsin, negative

Ultrasound examination of the abdomen and pelvis shows slightly echogenic hepatic parenchyma.

Which of the following is most appropriate for managing this patient?

A. Weight loss and improved glucose control
B. Pegylated interferon and ribavirin
C. High-dose prednisone
D. Referral for evaluation for liver transplantation

Answer

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