new grad - just wanted to clarify

[runnerpa-s]

Hello! I'm a new grad pa in primary care. I have some patients who incidentally are found to have hepatic steatosis on imaging. I wanted to make sure this approach sounds reasonable - can you give me some input? 

1. fatty liver on imaging - figure out the cause is the first step. likely 2/2 alcohol or obesity but confirm by checking some labs  (hepatitis antibody tests (A, B, C), AST, ALT, alk phos; up to date also says to check plasma iron, ferritin, TIBC, serum gammoglobulin level, ANA, antismooth muscle antibody, anti-liver/kidney microsomal antibody-1) 

----> are these done for every single patient or only for patients who you don't have a clear cause for their condition?

2. patients with fatty liver need hep A and hep B vaccines

- this only applies to patients with negative antibodies, right? if I have a patient with positive hep A antibodies, they don't need the vaccine, right? 

- these patients with fatty liver need the full vaccine series - not just a booster, correct? 

3. encourage patient to lose weight if NAFLD

4. refer if decompensating

5. if it's not biopsy confirmed, we don't check for fibrosis do we? unless the NAFLD score reaches around F3 or F4? 

 

I'm sorry if these questions seem silly. I'm still trying to figure out textbook medicine vs real world medicine and try to strike a balance

[ANESMCR]

On 6/5/2020 at 9:04 PM, runnerpa-s said:

Hello! I'm a new grad pa in primary care. I have some patients who incidentally are found to have hepatic steatosis on imaging. I wanted to make sure this approach sounds reasonable - can you give me some input? 

1. fatty liver on imaging - figure out the cause is the first step. likely 2/2 alcohol or obesity but confirm by checking some labs  (hepatitis antibody tests (A, B, C), AST, ALT, alk phos; up to date also says to check plasma iron, ferritin, TIBC, serum gammoglobulin level, ANA, antismooth muscle antibody, anti-liver/kidney microsomal antibody-1) 

----> are these done for every single patient or only for patients who you don't have a clear cause for their condition?

2. patients with fatty liver need hep A and hep B vaccines

- this only applies to patients with negative antibodies, right? if I have a patient with positive hep A antibodies, they don't need the vaccine, right? 

- these patients with fatty liver need the full vaccine series - not just a booster, correct? 

3. encourage patient to lose weight if NAFLD

4. refer if decompensating

5. if it's not biopsy confirmed, we don't check for fibrosis do we? unless the NAFLD score reaches around F3 or F4? 

 

I'm sorry if these questions seem silly. I'm still trying to figure out textbook medicine vs real world medicine and try to strike a balance

Hi there! Thank you for taking the initiative to learn more about fatty liver disease.

1)  Generally yes, fatty liver on imaging doesn’t tell you the definitive cause. In other words either refer to GI, or cover your ass with your listed labs. Alternative is to trend labs and evaluate med list. If still elevated order your panels and refer. 
Know what you’re looking for with each lab to better understand this. Addition to your list would be alpha-1-antitrypsin, AMA (mitochondrial antibody), celiac panel with ttg iga, ceruloplasmin, copper, PT/INR, and depending on your ddx AFP and TSH. Definitive answers come with a liver bx but you won’t have to worry about that bc GI will deal with it.

Know your patterns for liver enzymes. If ALP is also elevated, or alternatively the only elevated value, you can fractionate with isoenzymes and GGT. Patient is black? Add in ACE. 
 

Side note-as a PCP you should be screening for HCV in any pt btw 18-79 yo. HBV in pts from endemic areas. 

2) Yes and yes. However I would still recommend they avoid raw shellfish. And yes full series. 

3) NAFLD slow wt loss of 5-7% of body weight. About a pound every week or two. NASH 7-10%. Vitamin E supplementation 400IU/day. Optimize blood sugars/triglycerides/cholesterol. Avoid ETOH. Avoid Tylenol >2g/day.

4) Do your patient a favor and just refer right off the bat. Too often I get patients who have had fatty liver for years only to get referred when they have bridging fibrosis and cirrhosis. Order the labs and refer. 

5) Yes you can. U/S elastography, amazing tool we have now. F2 or greater would recommend liver bx and 6 month hepatoma surveillance.