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I am a doctor, a medical detective, and an award-winning TEDx speaker. I have been featured on CNN, ABC, NPR, the New York Times, and Newsweek. I have been featured in books including The Secret of Your Success and The Book of Secret Remedies . In addition to my work as a medical doctor, I am also an award-winning adventure journalist.This week, Dr Detective meets a middle-aged man suffering from a mysterious stomach ache and shows us that the liver can be just as sensitive to unhealthy foods as it is to too much alcohol.
Eat less and move more. All in all, an excellent recipe for improving your health and body composition. However, this does not always work.
Even with an excellent exercise plan and a solid diet, some people suffer from mysterious symptoms and ailments that seem incomprehensible when you consider how much effort they have put into their fitness and health.
When we meet clients whose problems cannot be solved by exercise or diet, let alone their own doctor, we know that there are few experts in the world to whom we can turn. One of them is Spencer Nadolski.
Dr. Nadolski holds a doctorate in osteopathic medicine and has also studied exercise physiology and nutrition. The college wrestler, who won the title of America’s best college wrestler, is still an avid athlete and a brilliant doctor who practices what he preaches to his patients: treat preventable diseases first by changing lifestyle (rather than prescribing drugs).
When clients have no one else to turn to, Dr. Nadolski transforms from a cheerful, athletic doctor into a meticulous, intolerant forensic physiologist. He pulls out his microscope, analyzes blood, saliva, urine, lifestyle – everything you need to solve a medical mystery.
When Dr Nadolski offered to collaborate on a regular article on case studies, we jumped at the chance. After following these fascinating cases, you will see exactly how a talented practitioner thinks. You will also learn how to improve your own health.
In today’s case, we meet a middle-aged man whose mysterious abdominal pain has finally been linked to his liver.
Walter, a 49-year-old man, came to me with abdominal pain.
I inherited Walter from another doctor who left the practice. It was our first meeting, but I knew he had been seen at our clinic for high blood pressure.
Signs and symptoms of the client
When I looked at Walter’s file, I discovered that he had never been diagnosed with anything other than mildly elevated blood pressure and high triglycerides. He also came to the practice with several colds and a sprained back. According to the records, he never complained of abdominal pain.
To find the cause of your problem, you have to work hard.
As always, I checked his vitals. Her blood pressure was still slightly elevated at 132/87, her weight was 223 (BMI 32) and her waist circumference was 43 inches.
As I walked into the room to meet him, I looked at my options in my head:
|Signs/Symptoms||My thoughts are potential problems|
|High blood pressure||Weight problems, stress, sleep problems, atherosclerosis, kidney, thyroid and adrenal problems.|
|Increase in body weight/waist circumference||Probably lifestyle factors, could be thyroid related (but unlikely), metabolic syndrome/insulin resistance.|
At first glance, nothing I noticed had anything to do with the stomach pain.
The only medication Walter took was lisinopril (an angiotensin converting enzyme inhibitor) for high blood pressure. He didn’t take any supplements.
Walter told me that the abdominal pain was dull, especially on the right side, and that it had been going on for a few months. On a scale of 1 to 10, with 10 being the worst pain he had ever felt, this pain scored 3.
The pain did not radiate anywhere and was not localized to one place. He also said that the pain does not change after eating or having a bowel movement. Nothing made it better or worse.
Hmmm. It wasn’t enough for me.
It was not easy to make a differential diagnosis. His background did not allow for a clear answer.
After talking to him some more, I started to press on his stomach. When I pushed, I couldn’t cause any pain and the bowel sounds were normal. I didn’t think his liver was enlarged. There was no evidence of gallbladder disease. He had no family history of pancreatic or liver problems.
Walter said he used alcohol, but rather sporadically – maybe 3 times a year. He followed the average American diet, rich in carbohydrates and fats, and exercised as much as the average American, which is obviously not much. It’s possible that lifestyle factors play a role in his pain, but I wasn’t sure yet.
It’s time to get tested.
Tests and classifications
Although there were no obvious signs of liver, pancreas or gallbladder problems, I had to undergo further tests. So I had a CBC (complete blood count), CMP (complete metabolic panel), lipase and GGT (gamma-glutamyl transpeptidase) done.
Biochemical blood analysis
The relevant results of Walters’ laboratory examination are as follows:
|Marker||Result||Laboratory reference area||Considerations|
|Fast glucose||115 mg/dl||65-99||Changed blood sugar. There is insulin resistance.|
|ACT||47 IU/L||<35||Some kind of inflammation/damage to the liver.|
|ALT||52 IU/L||10-35||Some kind of inflammation/damage to the liver.|
|Albumin||3.6||3,5-5 g/dl||Below. Maybe he’s not eating enough protein or his liver isn’t functioning properly.|
|Alkaline phosphatase||140 IU/L||44-147||On a higher level. This may be due to inflammation of the liver.|
|GGT||70 IU/L||15-80||On a higher level. This may be due to inflammation of the liver.|
|Plaques||160 x10^9/L||150-400||Below. This may be due to poor liver function.|
|Direct bilirubin||0,2 mg/dl||Normal.|
|Total bilirubin||0,6 mg/dl||0.3-1||Normal.|
|Prothrombin time||13 seconds||11.4-14.2||Normal. It is an indicator of the quality of blood clotting, but since protombin is made in the liver, it can indicate liver function.|
|Lipase||30-210 U/L||Normal. It is an indicator of the quality of blood clotting, but since protombin is made in the liver, it can indicate liver function.|
Walter’s tests showed he had an inflamed liver. When I see this, I do regular hepatitis testing and look for hepatitis B and C.
Walter’s tests for hepatitis were negative. This was great news, but we still didn’t know what was going on.
If the liver enzymes are similar to hers, alcohol abuse should always be suspected (although the AST:ALT ratio is probably greater than 1 in alcohol-related hepatitis). But Walter insisted that he rarely drank.
Drugs and supplements can also cause liver damage, but again, Walter took nothing but Lisinopril for his blood pressure.
I rolled up my sleeves to do some more research.
At the time, I thought Walter might have hemochromatosis (iron overload disease). I asked for iron tests, but ferritin (which indicates iron supply) and transferrin/TIBC/iron levels were normal. Finally, I ordered an ultrasound of the right upper quadrant – and, you guessed it! – It turns out that this is also normal.
The only possibility I could think of was that Walter had non-alcoholic fatty liver disease (NAFLD for short). But the only way to confirm this may be a liver biopsy – not to be taken lightly, of course. There are also special ultrasound and MRI scans, but these may or may not reveal anything.
There was a status quo. But given Walter’s metabolic syndrome, NAFLD seemed like a plausible diagnosis. I decided to put it to the test. It is time to change your lifestyle and take effective supplements.
We usually associate liver disease with excessive alcohol consumption. In fact, drinking too much is not good for the health of the liver. Chronic heavy drinking can lead to inflammation and fibrosis (hardening of the cells) and fat deposits (steatosis).
But many people are unaware that the same problem can occur with obesity and metabolic syndrome (which includes insulin resistance and poor blood fat processing, as well as inflammation throughout the system). When you have too much fat in your body, it doesn’t just accumulate on your buttocks and tummy – it also accumulates around and in our internal organs. The liver is the main center of cell signaling, conversion and processing and is therefore often one of the organs most affected by malnutrition and excess fat in the body.
Although heart disease and stroke are receiving increasing media attention, experts suspect that fatty liver – also known as non-alcoholic fatty liver – is one of the lesser known, but more common, consequences of obesity and poor diet.
Walter’s second visit
During Walter’s follow-up, I explained the situation to him. We couldn’t be sure without a liver biopsy, but his insulin resistance probably contributed to the liver disease. Instead of breaking down the fats, his liver held on to them and regularly swam in a cocktail of free fatty acids. Not really.
Walter understood and agreed to address the problem. I told him it wouldn’t be easy, but if he stayed with Dr. Detective for the next few months, we could solve the problem together. We start with a progressive weight loss plan and some supplements.
Since Walter’s diet was far from optimal, there was much room for improvement. The only question is where to start.
Fix #1 – Speed change
Walter liked lemonade and sweet tea. But abandoning them would have been a relatively easy change, so we decided they should leave. We also agreed that he needed more protein in his life.
Yes, I took a risk asking Walter to adopt two new habits at once. But he was motivated. And I decided that if he could focus on eating calorie-free drinks and lean proteins for the next few months, we’d be on the right track.
Walter loved coffee. Since coffee has been shown to be beneficial for NAFLD, I told him he could benefit, provided he sweetened the coffee with stevia.
Correction #2 – Fish oil
Walter suffers from hypertriglyceridemia (high triglycerides) and I recommended that he take a high dose of fish oil to combat this problem. Fish oil has not (yet) been proven to help with NAFLD, but it can’t hurt. Along with reducing carbs (avoiding sugary drinks), this may be the key to changing your overall metabolic profile.
Fix #3 – Berber
Because berberine may contribute to insulin resistance and some small studies have shown it may be helpful in NAFLD, I added it to Walter’s diet.
Over the next few months, Walter and I communicated via e-mail. He has had good days and bad days, but overall he has improved his lifestyle significantly.
After three months, Walter came back to the office. The abdominal pain is mostly gone. Bingo!
But he was even happier when he announced that he had lost seven inches off his waist. He has also lost a total of 18 pounds since I first saw him. It may not seem like much, but for Walter it made a big difference.
To verify that the internal changes correspond to the visible changes, we repeated the liver enzyme tests. Both results showed about 30 IU/l – within the normal range.
Today, Walter keeps visiting me at the weight loss clinic. He has also started going to the gym where he trains 3-4 times a week. After starting with changing just two habits, Walter is on his way to a healthy future.
So what can we learn from Walter’s story?
- Alcohol abuse is not the only way to damage your liver. Without intervention, Walter’s liver could have become as sick as an alcoholic’s.
- If you have indistinct abdominal pain (or any abdominal pain) and it persists for more than one or two weeks, you should see a doctor. Don’t neglect the health of your vital organs!
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