The patient is a 50 year-old male diagnosed with liver disease of unknown causes in cirrhotic evolution and portal hypertension. He is pathologically obese (BMI 39) and had a period of hypertransaminasemia, markers showed negative for hepatitis B as well as later for hepatitis C.

Occasional periodic check-ups for thrombocytopenia led to further investigation with a final diagnosis of liver cirrhosis of unknown causes. On that occasion a bone marrow biopsy was carried out which revealed the following: bone marrow sample with normocellular blood marrow containing elements of all the maturative series free of lymphomatous localization. A modest increase of argentophile reticulum.

The CAT scan showed a liver of reduced size especially on the left side, with a cirrhotic liver morphology, without focal lesions. Signs of portal hypertension with the presence of collaterals around the splenic hilar and the recanalization of the umbilical vein.

A consultant specialist held that the pathology could have immune origin. Viral markers remained negative except for virus A, AMA tested positive once but was not confirmed at a later check-up.

Liver ultrasound: liver uneven and rough on the edges with coarse, irregular texture, like chronic advanced liver disease. The portal vein is patent with a diameter of 19 mm. The umbilical vein is patent. The spleen has a diameter of about 20 cm.

An esophagogastroduodenoscopy showed: “presence of initial blue straight varices, with no signs of hemorrhagic risk. Hypotonic cardia with z-line re-lifting. Normal distansible stomach tissue: fundus and body mucus normal, free of subcardial varices. Small erosions are visible in the antral area. Central pylorus, normal. Nothing in the duodenum even in the second part.” The specialist insists that the patient, with reduced liver capacity, could be compatible for a liver transplant evaluation, however it is inadvisable at the moment because of his pathological obesity (a diet is strongly advised). The hepatic biopsy gave the following result: <<”End stage” moderately active liver cirrhosis with defined ductal biliar neogenesis and steatosis foci. Moderate hepatocytic and Kupffer’s serous fluids.>>

Online Doctor Consultation – Medical Questions: The patient would like to ask a doctor for an opinion on possible causes of the disease and if there are any medical treatments effective at halting development of the disease with an eventual reference of where to go. The doctors at the medical services have advised him to lose substantial weight before being put on the transplant list. What are his chances if given a transplant and where could he safely undergo it?

Expert Report and Opinion

Summary: The patient is a 50 year old male with obesity and cirrhosis. His cirrhosis is complicated by thrombocytopenia and depressed albumin, as well as signs of portal hypertension on cross sectional imaging and endoscopy (varices). There is no reported history of jaundice, encephalopathy, ascites, portal hypertension bleeding, or hepatocellular carcinoma. Serological evaluation failed to support a diagnosis of autoimmune liver disease, hemochromatosis, or Wilson´s disease. Viral serologies were reported to be negative, in the narrative case summary.

Impressions: It is my impression that the patient is suffering from cirrhosis attributable to his obesity. He may have the sequallae of non-alcohol induced steatohepatitis. Despite this, thrombocytopenia, hypoalbuminemia, and portal hypertension with varices are the only signs of advanced chronic liver disease. Given the lack of significant elevations in bilirubin or INR, and absence of ascites or encephalopathy, he does not appear to be in urgent need of liver transplantation. This opinion not withstanding, he is likely to require liver transplantation in the future. However, his current weight (BMI 39) puts him at great risk for perioperative complications, should he undergo transplantation. In fact, he would not be considered a candidate at our institution with a BMI over 35.

Recommendations: The patient requires intensive diet management, by a trained dietician. Weight reduction in cirrhotics may be problematic, as these patients are prone to malnutrition and the BMI may not account for the other factors affecting the weight such as anasarca and ascites. There is no other treatment I will recommend the patient. If he can reduce his weight to BMI 35, liver transplantation should be pursued, as the procedure may have acceptable safety at that point.