How to reduce excess weight due to liver enlargement?

Hello,

Welcome to icliniq.com.

I can imagine how upset you must be about your overweight and liver issues. Well, I assume you now have a thorough idea of how this weight bears an impact on your liver. And with such amount of weight it is not uncommon to have a fatty liver disease with enlargement of liver size. The normal liver size should be no more than 13 cm.

Despite the fact you have severe morbid obesity, thankfully you deserve a vote of appreciation for struggling so high to reduce your weight by 33 lbs . This is a good sign by the way. I would urge you to continue this in future whatever you were doing for the weight reduction. Since you did not mention whether you still having alcohol and smoking? It is important to know that fatty liver plus alcohol can both damage the liver and the impact is much higher if both risk factors are combined. I should strongly recommend you to reduce the alcohol intake if still taking or completely stop it. Your liver may not be able to tolerate more insult because of alcohol.

Now coming to the numbers which you have shared. The Kpa value more than 12 is suggestive of the development of fibrosis which is not a good sign. However, this value is often erratic or falsely high if someone has obesity or fat within the liver as may be in your case. To confirm whether you have that degree of fibrosis, you have to get a liver biopsy which can tell the exact grade of fibrosis and can differentiate whether the insult to your liver is because of alcohol you had in past, or because of fat due to obesity. The CAP value of 353 is suggestive of the amount of fat you have in the liver. This can however, indirectly confirm the damage to your liver is rather secondary to fat and not due to alcohol but again this has to be confirmed on liver biopsy. If you are not inclined to liver biopsy, I suggest you to continue with the weight reduction strategy, completely avoid alcohol intake and keep monitoring your liver function tests and fibroscan every six months.

Hello,

Welcome back to icliniq.com.

I have reviewed you all reports (attachment removed to protect patient identity), I could not figure out why your previous physician has done lots of TNF-alpha levels which has no role in management of this case.

The other tests particularly your liver function tests shows raised SGPT (sserum glutamic pyruvic transaminase) and SGOT (serum glutamic-oxaloacetic acid) which are suggestive of ongoing fat related or alcohol related damage. Your HbA1c (glycated hemoglobin) is 6.1 dated feb 2020, which is suggestive of that you have diabetes as well.

So to conclude it seems you have metabolic syndrome or syndrome X which is characterized by obesity with waist circumference of more than 40 inch, raised triglycerides more than 200 mg/dl, presence of diabetes. The presence of liver insult is also secondary to fatty deposition. You did not share if any liver functions tests that have been done earlier before your weight loss, otherwise it would have shown significant improvement since you have lost 33 lbs of weight thereafter.

Thankfully despite of your weight, or alcohol use, I could not see any sign of advanced liver disease /liver scarring on biochemical investigations. Albumin, platelets which are well within normal limits and this is a very good sign. Another good news is that it is only alcohol related liver disease and fat related liver disease which both can regress once person avoids alcohol and reduces weight. So thankfully both are reversible conditions, and I assure you it is still not late, we can still reverse it back to normal.

I suggest you continue loosing weight, make a target that you loss an additional 33 lbs of weight in coming six months. I think this is a reasonable and a descent goal that you can achieve. Also for your abnormal liver function tests and diabetes I suggest you to start tablet Pioglitazone (thiazolidinedione) 15 mg once daily with meals, and tablet Sitagliptin (dipeptidyl peptidase-4 inhibitor) 50 mg twice daily half an hour before meals.

Keep monitoring your sugars-one at fasting and one after two hours of taking meals. At least make a chart for one to two weeks time. Tablet Pioglitazone is very helpful in improving liver function abnormality in your case. But it has one common side effect which is peripheral edema (accumulation of water over feet). But I believe it will not occur since I am starting you on very low dose of now (the maximum dose is 45 mg daily). Lastly for your altered lipid profile, start Rosuvastatin (anticholestrol) 10 mg daily at night time. I want you to repeat your fasting lipids, liver function tests within two weeks times.

Lastly, I could not see CT (computed tomography) scan reports of all you uploaded. Yes, CT scan can give us idea of liver parenchyma damage and also can show features of advanced liver disease such as cirrhosis of liver and portal hypertension which is one of the complication of liver cirrhosis. And you did not tell me about your current alcohol intake and smoking. Please reply.

Hi,

Welcome back to icliniq.com.

That is very good news that you have stopped taking alcohol and smoking. I have again reviewed your test. Yes, the last ultrasound report dated 31/5/2020 showed different findings than your previous ultrasound. Actually, you see these all ultrasound reports have been done at different time points, and by different sonologists, so it does not really bring any surprise to me of their different reported findings.

Secondly findings such as spleen enlargement, portal vein dilatation up to 14 mm, suggest progression of your existent liver disease. They are evolving complications of the chronic liver disease, liver cirrhosis, or liver scarring. If the things are not controlled now, they will go on to develop fluid in abdomen called ascites. Thankfully your blood reports including albumin, and platelets count are within normal limits, once they start decreasing, the situation can get even more worse.

These changes are expected to occur in your case and can go to more worse side or to more favorable side. I am sure, if you go one work out more like weight reduction and using medicine as I prescribe you, the things can get reverse and more favorable in future.

So the final plan of action is tablet Pioglitazone 15 mg once daily with meals and Sitagliptin 50 mg twice daily half hour before meals, Rosuvastatin 10 mg daily at night time. Do weight reduction. Your sugar and your weight has to be strictly monitored while you are on these medications. I would like to see you in two weeks with liver functions test and fasting lipid profile and sugar charts maintained over two weeks.

Hello Mr. Sharma. I welcome you again on icliniq. I have reviewed your current regimen as prescribed by ILBS (institute of liver and biliary science). You can take Saroglitazar instead of pioglitazone because the former is also helpful in treating liver dysfunction and have shown some good results in experimental animal studies. Some studies on saroglitazar has been initiated in India, however; in western countries it is not yet FDA (food and drug administration) approved. The preliminary data on human subjects and Some experimental data on rats has shown saroglitazar performing better than pioglitazone. If you ask me personally I have had no experience with saroglitazar. Thats why did not prescribe it to you. But you can discuss this thing with your treating physician in ILBS, I really hope he must have some good experience with saroglitazar. 2. You should not start rosuvastatin which I prescribed you earlier. 3. You have been prescribed Metformin(biguanide) twice daily. And I have given you sitagliptin 5o mg twice daily. Take both of these medications. These both salts are combined in to single with name of Tablet Sitamet 50/500 mg (sitagliptin), or similar brand available in India. you should take one tablet twice daily. 4. I suggest you to stop UDCA 450 mg (ursodeoxycholic acid). Since it has no proven role in treatment of fatty liver disease. So to conclude Take saroglitazar (lipaglyn). Take Sitamet (sitagliptin+ metformin) 50/500 mg twice daily Stop or do not take Rosuvastatin (antihypertensive) Stop UDCA (urso deoxycholic acid) 450 mg. I hope this has answered your concern.