6.23 AM reports pearls from SFGH: DM complications and iron overload

Take home pearls:
·         Iron studies can be elevated for reasons other than iron overload including: alcoholic liver disease, NASH/NAFLD, and chronic viral hepatitis
·         Diabetic amyotrophy (aka Bruns-Garland syndrome) is characterized by proximal leg pain and weakness, though usually more acute and within the first few years of diagnosis.
·         The differential for common bile duct dilation in the absence of biliary symptoms includes duodenal diverticula, benign strictures, CBD masses, choledochal cysts.
·         ethyl glucuronide is metabolite of ethyl alcohol formed by glucuronidation of ethanol from drinking alcohol. It is sometimes used a biomarker to assess abstinence from alcohol (for liver transplant, professional monitoring, etc) that is detectable longer than actual ethanol.  However, it is an imperfect test and other exposures can cause false positives and evidence does not support its use for monitoring of ongoing alcohol use!
Additional learning points for your files:
From her proximal muscle pain and weakness –
 
·         For diabetic amyotrophy, proximal hips, thighs and buttocks are the areas most commonly affected, and most patients have associated new autonomic symptoms, including orthostatic hypotension!
o   Many patients recovery spontaneously (there are no known treatment options currently), but most will require a wheelchair or other walking aid for some period of the illness and recovery may not be fully to baseline
·         Diabetes is also known to cause myopathy due to microinfarctions of muscle tissue, usually in longstanding disease and in people with other vascular complications of DM.
o   This can cause subacute onset of muscle pain and swelling, and frequently is associated with elevated CK and ESR. This also is usually a self-limited condition with no known effective treatment options
 
 
For her elevated iron studies –
·         Remember that women with hemochromatosis will usually present much older than men because menstruation attenuates their iron accumulation until menopause
·         Liver biopsy is the definitive diagnostic tool for hemochromatosis and pathology uses a 1-4 grading system and Prussian blue staining to characterize the degree of iron infiltration
 
 
For her liver findings –
·         The differential for common bile duct dilation in the absence of biliary symptoms includes duodenal diverticula, benign strictures, CBD masses, choledochal cysts.
·         In these cases, endoscopic ultrasound (recommended for this patient) can be useful in reaching a diagnosis, but ERCP should be performed if intervention is likely to be needed.
o   For this patient with history of gastritis and H. pylori, EGD and/or ERCP should be done to evaluate for malignancy
 
Evernote link:
 
 
 
 
Holm A, Gerke H. What should be done with a dilated bile duct? Curr Gastroenterol Rep 2010. April 12(2) 150-156.
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