Question of the Week

For January 23, 2018

A 55-year-old man with type 2 diabetes, hyperlipidemia, and obesity is referred for evaluation of persistently abnormal liver enzyme levels. His efforts to lose weight have not been successful. He consumes less than one alcoholic beverage per month.

On examination, his blood pressure is 145/89 mm Hg, and his heart rate is 76 beats per minute. His BMI is 31. His abdomen is soft and nontender. His liver is of normal size, and his spleen is slightly enlarged on palpation.

Laboratory testing yields the following results:

Patient value

Reference range

Alanine aminotransferase (U/liter)



Aspartate aminotransferase (U/liter)



Alkaline phosphatase (U/liter)



Total bilirubin (mg/dL)



Platelet count (per mm3)


150,000 – 350,000

Hematocrit (%)


41.0 – 53.0

Testing for hepatitis C antibody, hepatitis B surface antigen, and autoantibodies is negative. Transferrin saturation levels are normal.

Ultrasound of the right upper quadrant reveals diffuse fatty infiltration of the liver and slight enlargement of the spleen.

In addition to recommending weight loss and exercise, which one of the following management approaches is most appropriate for this patient?

Repeat liver enzymes in 6 months
Refer for Roux-en-Y gastric bypass
Initiate treatment with vitamin E
Perform MRI of the liver
Perform percutaneous liver biopsy