Q. I have fatty liver with dizziness, heel pain and morning headaches. Please help.

Answered by
Dr. Ajeet Kumar Lohana
and medically reviewed by Dr. Vinodhini. J
This is a premium question & answer published on May 27, 2020

Hello doctor,

I had a problem with lower left abdominal pain for 7 years which is diagnosed in 2017 as an umbilical hernia. I subsequently did the surgery in January 2018 and I was diagnosed with moderate fatty liver during the test prior to the surgery. But I was given Liv 52 to take for three months and Lipitor 20 mg. But when I reported to work I started noticing mild pain in my heels and imbalance which I thought was due to the drugs side effects. Somewhere in March I panicked out of sleep and started sweating with my heart beating very fast. I rushed to the hospital and they did a brain CT and kidney function test which was normal and the gave me some anxiety tablets Lexotamil 1.5 mg.

Afterward, I noticed that my heel pain was aggravating with flashes of dizziness and minor headaches which I could manage. I reported to the hospital and was referred to an orthopedic specialist. There I was asked to do and MRI of the brain, neck, and spine with magnesium, phosphate, calcium, and sodium test which were all normal. The doctor then gave me Renerve and Stugeron for the dizziness. But still the issue persisted so I reported back to focus and was asked to see and ENT specialist and EYE specialist. I went to an eye center but they all proved negative. So I was referred to see a neurologist who asked for an MRI of the thoracic and lumbar spines and also test for Folate and Vitamin B12. But again they were all negative and he said my situation might be idiomatic so he did not give anything.

But in all these, I realized my energy levels were coming down I easily get tired and occasionally my heart rate will go up with a feeling of uneasiness and confusion all coupled with balancing disorders associated with cluster headaches. I went back to my hospital and was advised to see a cardiologist. He also did his relevant test which all proved negative and he declared me safe. But he advised if I am still not normal I should see his boys at the executive heart center which I did. They have been working on me since and nothing has come up. Although the symptoms still persist. So just last week I was not feeling very well and had to go for a check up when I was told of the micro-pulmonary embolism and was admitted.

I currently have serious heel pain without swelling in the legs, dizziness without spinning, chest discomfort, unsteady gait, muscle weakness and extreme fatigue, diminished vision, issues with acid reflux and indigestion, occasional heart palpitations, insomnia, and pressure and discomfort in the chest after standing for about 5 minutes or while walking with extreme dizziness.

I currently take Xarelto 15 mg, Motilium once daily, Stugeron 25 mg, Maalox plus suspension 150 ml, Pariet 20 mg, Carvedilol 6.25 mg, and Lexotanil 1.5 mg once daily at night.

Dr. Ajeet Kumar Lohana

Medical Gastroenterology
#

Hello,

Welcome to icliniq.com.

I can imagine how difficult time you have doing all these visit to doctors. Well, I have gone through your history, I could not see you have any specific gastrointestinal issues at this moment. Your main concerns are related to the neurological department not a gastroenterology department. I urge you to seek help from a neurology team.

Well, some of your concerns like fatty liver, and indigestions are related to my field, hence I would like to give you some suggestion regarding that. So I see you already on some medicine for indigestion such as Maalox syrup and Pariet which is an acid suppressant medication. They are relatively safe and can be taken regularly or intermittently based on symptoms.

The second concern from GI prespective are fatty liver. You did not mention your weight so I could not estimate the body mass index which is a direct tool to assess the level of fat one has over the liver and other body tissues. Atorvastatin (Lipitor) can reduce some fat from liver but they are not the preferred treatment for fatty liver disease, they can control lipids however if elevated. Atorvastatin can cause myopathy means muscle damage and can cause severe cramps over legs and throughout the body. I want you to check your creatine phosphokinase (CPK) levels to confirm this if you have recently stopped your Atorvastatin.

The preferred therapy for fatty liver disease, if you are not diabetes is Vitamin E 400 mg twice daily for at least three months. The other recommendation is to reduce your weight by 7 to 10% of current body weight in the coming six months. Walk 150 minutes/week and dieting which is all required.

I am sorry I could not answer the rest of your concern, but I want that should contact a neurologist available online on icliniq to be given proper suggestions regarding your health.

I hope this helps.


The Probable causes:

Fatty liver disease. Indigestion.

Investigations to be done:

Creatine phosphokinase.

Differential diagnosis:

Drug-induced indigestion.

Treatment plan:

Capsule Vitamin E 400 mg twice daily for three months.

Regarding follow up:

You can follow up with me for your GI related issues, and discuss long term management of your fatty liver disease.


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Hi doctor,

I have attached files. Please take a look.

Dr. Ajeet Kumar Lohana

Medical Gastroenterology
#

Hello,

Welcome back to icliniq.com;

I have again reviewed your history and now with investigations that you have done so I am telling you step by step.

Your blood investigations including liver functions test shows abnormality. This seems secondary to fatty liver disease. You did not mention your weight again. Otherwise, I would have been more confident telling you that this liver function abnormality is due to overweight and not secondary to other cause. The ultrasound report also suggest that you have fatty liver disease. which is supportive evidence. I will advise you a few more tests to make sure that it is definitely the fat in the liver causing abnormal liver functions test and not necessarily due to other diseease process like hepatitis viral infections.

Your lipid profile is also abnormal, but since you do not have any established heart disease, kidney disease, or a brain disease given your previous MRI including brain and spine were normal; I think these lipid abnormalities are not alarming. Once you control your weight, your thing will settle. Just keep an eye on total HDL/total cholesterol ratio, which should be less than 4.1. In your case it is 4.5.

After revision of your history now in light of investigation that we have, I think the symptoms you mentioned like weakness, dizziness without vertigo, extreme fatigue and apathy (loss of interest), low energy and tingling and cramping in legs; are secondary to drug side effects. The most common of which is Carvedilol and partly contributed by Domperidone (Motilium). I want a thyroid function and blood sugar testing to rule out these underlying endocrinological disorder mimicking your symptoms. Stugeron 25 mg is also an antihistamine that can cause increase sleep, fatigue and increased or altered pattern of sleep.

So to summarize, there are abnormalities in liver function tests, and lipid profile, both will go away after you start the medication I suggest you and after reduction of 10% of your current body weight. You please share with me your current height and weight, as I can be in better position to guide you regarding that. Similarly your indigestion issues can be secondary to weight, and would improve if you follow above recommendation, plus I give you some medication for that as well. Plus once I have your weight, while on background of abnormal liver function tests and abnormal lipid profile, I am afraid you have metabolic syndrome.

Your rest of the symptoms seem to be secondary to drugs side effects particularly Carvedilol and Motilium. I suggest you to stop Motilium immediately and discuss with your cardiologist to decrease the dose of Carvedilol or consider switching to other medication of similar class with low side effect profile. For Stugeron 25 mg, you can stop this if you do not have allergies, flu or post nasal drip. Stugeron 25 mg should be taken for shorter period of time not for longer use. Stop Pariet and Maalox. I will give you others instead of these.

See me after the investigations I have suggested you below and update me about your symptoms after following above recommendations.


The Probable causes:

Indigestion.
Fatty liver disease.
Metabolic syndrome.
Drugs side effects.

Investigations to be done:

TSH, FT4, FT3, random blood sugar, HbA1c, check waist circumference in inches, current weight and height, HbsAg, and anti HCV antibody (for ruling out any other cause for abnormal liver function tests).

Probable diagnosis:

Indigestion.
Fatty liver disease.
Metabolic syndrome.
Drugs side effects.

Treatment plan:

Cap Esomeprazole 40 mg half hour before breakfast (this is instead of Pariet).
Syrup Mylanta 15 mL 4 to 6 hourly after meals for 5 days and thereafter if indigestion recurs. (This is instead of Maalox).
Cap Evion 400 mg twice daily for 3 months (do not start this medication now unless I see your blood sugar and HbA1c report).
Stop Motiliumand Stugeron 25 mg, and consult your cardiologist for Carvedilol.
Reduce weight by 10% of your current body weight.

Preventive measures:

Take no more than 1200 to 1500 kilocalories a day. Avoid carbs in diets, juices, cold drinks, and sweets. Can take whole fruits instead of fresh juices. Avoid taking energy drinks. Exercise regularly. 150 min/week brisk walking. Running is preferred. Target weight loss in 6 months' time.

Regarding follow up:

Follow up after investigations and to discuss improvement in your symptoms or contact any time if required.


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Hello doctor,

Thanks for the quick response. My weight is 165 pounds, height is 5.10, and waist in inches is 37. I have attached all the relevant test as requested. Thank you.

Dr. Ajeet Kumar Lohana

Medical Gastroenterology
#

Hi,

Welcome back to icliniq.com.

Perfect! Thanks for sharing rest of the investigations and updating me about your weight and height.

I have calculated your body mass index (BMI) which is weight proportionate to your height. It is 23 and it is perfectly normal. You need not reduce weight, but just maintain it within this range.

Now there is possibility that you do not have metabolic syndrome at moment. The metabolic syndrome comprises of waist circumference more than 40 inches in male, triglycerides more than 150 (which you do not have), diabetes or pre-diabetes (present in you), hypertension (negative), and liver function abnormalities (which you have). So, the criteria is half filled. The criteria can develop in recent future if things are not taken care off now. So do not be anxious just be cautious.

Your HbA1c is just above the upper limit of the normal which is 5.9. You can start the tablet Pioglitazone 15 mg with meals once a day (I have written generic name of the medication, you can take whatever brand available in your country with the same generic formula). This medication will maintain your weight and correct your fatty liver disease. This medication can cause some side effects, most of which are amenable to small changes in drug doses, and often not serious. The common side effects are water accumulation over feet (this is called edema of feet) and low sugars called hypoglycemia in 25% of individuals. Remember I am starting at low dose (maximum dose is 45 mg once daily), so these said side effects are unlikely to happen in your case. I want you to closely follow up as to titer the doses of medication while assessing improvement in your liver function tests and watching for development of any side effects.

Do not start Evion since you have diabetes, and Evion is not recommended in this situation.

Lastly I am allowing you to one free follow up to tell me whether you take any alcohol. If not then perfectly fine. If yes, then tell me how much? and which one, beer or whisky?


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Thanks doctor for your response,

But on the issue HbA1c test and the possibility of type 2 diabetes, I would like to conduct the test again tomorrow to confirm that properly to you before I start the treatment regime. This is because 3 years ago a lot of study was done on this by the doctors here when I reported of frequent urination and they even thought at point that I have issues with my prostate but after a lot of test and study they could not find anything unusual.So, I have consistently being checking my FBS in the house since but nothing has come up.

Dr. Ajeet Kumar Lohana

Medical Gastroenterology
#

Hi,

Welcome back to icliniq.com.

Yes, you are right. You can check HbA1c again but not tomorrow. Ideally it should be done over a period of 4 to 12 weeks. You can test it in next month of course. If you get your test now this would come within this range. And, I did not start Pioglitazone just considering diabetes it is to help you to improve your liver function test. Many studies has found beneficial role of this drug in treating non alcoholic fatty liver disease (NAFLD). And unluckily the LFTs you shared with me are not within normal limits and have to controlled with one or the other medication. But I give you complete control over your decision. You let me know when you are ready then we can start this.

Have a nice time. Take care yourself.:)


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Hello doctor,

Thanks again for your quick response. If you look at the test I did on the HbA1C, it was done in December last year. So, I thought it will be prudent to check it again for you together with the FBS. But I hope I can go ahead with the other medications regarding the acid reflux. Thank you.

Dr. Ajeet Kumar Lohana

Medical Gastroenterology
#

Hi,

Welcome back to icliniq.com.

Oh I missed! I am sorry. I thought all tests were done recently since I seen the dates of reports you upladed earlier. Yes, then you just check it now and FBS as well. Let me know the report once done. And I again emphasize to think about Pioglitazone or else we have other options but they are again medicinal one. Have a good day.


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Hello doctor,

I have gotten the test done and wanted you to have look at them. But, I also have these issues now which I dont know related to the earlier problem presented. I have severe pain in may right shoulder when I eat and gets dull after eating though I still feel the pain a little bit. The pain radiates to the bottom of my right breast and also when I eat I feel a strong urgency to go to the toilet. All these are accompanied by pain in my legs and especially the heels after eating and when I sit or lie down and has been present for sometime now.

Dr. Ajeet Kumar Lohana

Medical Gastroenterology
#

Hello,

Welcome back to icliniq.com.

I hope you must be doing great. Well I cannot see this uploaded file. You can tell me te result. It seems some problem while uploading file in this chat.


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Hello doctor,

Sorry, I have sent the files again.

Dr. Ajeet Kumar Lohana

Medical Gastroenterology
#

Hi,

Welcome back to icliniq.com.

Yes, I can see now. The HbA1c is still in the upper limit of normal. You can consider it as prediabtes if not frankly diabetic. But you know they are just a number, and they frequently change in number given methods of their testing, physiologic condition of the body and hydration status of the body when the test was being performed. I suggest you to take precaution as a diabetic patient do, like avoiding sugary items, avoiding fatty and carbohydrate rich diets. Do regular exercise, and just keep you wight maintained.

For abnormal total cholesterol to HDL cholesterol, which is still abnormal, I suggest you to start Tab Rosuvstatin 10 mg at night time. This is lipid lowering medication with expected effects in coming 2 to 4 weeks. I would ask you to repeat fasting lipids in 2 weeks' time and show it to me. Lastly, I think it would be good if you consider starting Tablet Pioglitazone at least 15 mg daily with meals. This will help in short as well as long term. I just want to hear from your take on this.


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Thanks Dr for ur input. Well you are the Dr and if your recommendations will solve my problem y not. I was just concerned about being diabetic and the issues of the side effects of the drug u mentioned. And does the Fbs has a relationship with the Hb1ac You didn’t also address the other issues I mentioned. Kindly advise me on that please.

Dr. Ajeet Kumar Lohana

Medical Gastroenterology
#

Yes FBS has relation with HbA1c. Both are basically measurements of the blood sugars in blood. FBS tell the sugars after fasting , while HbA1c shows status for last 3 months of average sugar levels. But both have their own interpretation in the scenario. I understand you feel the pain over right shoulder and which radiates to right breast, this pain does is accompanied by leg pain and heel pains. This pain worsen when you lie down or when you sit. You feel strong urge to pass stools when you eat meals. well the pain you feel is because of distension of you small bowel, and they can cause pain which is referred over right shoulder and right side breast. This condition seems to be post prandial distress syndrome (PPDS). Prandial means meal. Post prandial means after meals. This condition is again associated with high blood sugars. The human blood sugars has to do lot with gastrointestinal tract. As one such example, with increased levels of sugars after meal can cause slowing of stomach and small bowel motility and can cause accumulation of large amount food within upper part of gastrointestinal tract with lots of gases. This can cause symptoms that you are mentioning. I suggest you to divide you meals in to portions. Instead of 3 to 4 regular meals in a day, divide it in to 6 to 8, and take the same amount of calories in a day but with increased frequency. You should take Tab Levosulpiride 75 mg half hour before meals twice daily. This is prokintetic medication which promotes stomach and small bowel motility and will improve your symptoms. You take for 2 weeks now and then intermittently when required. The strong urge to pass stools is not uncommon in post prandial distress syndrome.


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Thanks Dr Once again. So I want to believe that this high value in Hb1ac and cholesterol may be the reason why I have had issues with my heel and legs for about a year now, constant loss of energy drive and associated dizziness spells and sometimes issues with sleep and panicking out of sleep and other related problems like arrhythmia and now I can had do an activity and I get tired so easily.

Dr. Ajeet Kumar Lohana

Medical Gastroenterology
#

well you can say that. Diabetes and hyperlipidemia can cause blood vessel narrowing which can cause nerve damage. These both disorders plus hypertension (which you do not have) are the conditions which can affect human body form head to toe. Drug side effects are common but they can be easily controlled on regular monitoring. These drugs also help individuals to gain back their health. so please remember that as wll Hello. Did not hear from you. You can start the treatment and see me in 2 weeks time. I hope things will be in better shape then. good day


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Wanted your opinion on the attached file and also Wanted to know if you could help with the other conditions you mentioned were neurological As in the heel pain , disorientation, geeting tired easily and can’t stand for long without feeling swaying and can’t walk for a long time too and there are times I get shortness of breath. Also I feel extremely fatigue and there are times I feel like about to go off and the situation has not being getting better though I have being on so many drugs and currently on Xarelto 20mg daily

Dr. Ajeet Kumar Lohana

Medical Gastroenterology
# Hello. well there are obvious thromboembolism in both sides of pulmonary arteiers. May be this causing low oxygen in blood and hence easy fatiguability. xeralto has been started because of this. I suggest you to take an advise from a pulmobolgist. I may not be best person to give you advise on this.

pulmonologist

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This Kwame again.

The first day we chat I complained of a heel pain which I have being experiencing for about 3 yrs now and now I have serious muscoskeletal issues where u said I should do a CPK and wanted u to see if that will help with some explanation because is not easy for me now.
Movement has being very difficult for me now seriously

Dr. Ajeet Kumar Lohana

Medical Gastroenterology
# Hello Dear Kwame. Welcome again to icliniq.
I feel really sorry you are in pain.
Yes I know I have suggested CPK and also have seen this report earlier. This was normal by the way. The CPK is just at the upper limit of the normal. For CPK to explain musculoskeletal pain it has to be in range of thousands, which it is not. The just upper limit of the normal can simply be due to many reason; few common of those are just above average or sternous excercise day before the test; even an intravenous and intramuscular injection can increase the CPK in some hundereds. So it is abnormal in your case.
Coming to your heel pain; since you are very young to develop any orthopaedic (bone related) related condition such as osteoporosis or osteopenia due to underlying Vitamin D deficiency; I thought it would be useless to test for it. But since you have continues pain I suggest you to check your vitamin D level.
Plus to rule out other possibility of calcaneal spur, which is a bony projection from one of bone od feets. It can cause pain, severe at times and usually present when walking. This can rasily be seen on x ray heel lateral film. I suggest you to get it done.
The systemic symptoms as we mentioned earlier are more likely to drug side effects. The common of which is carveda. I suggest you to discuss with your physician for consideration of reducing dose or stopping it and see if it improve your symptoms.

For your pain I suggest you to start Tab Nuberol forte ( Orphenadrine plus paracetamol ) thrice daily for 3 days and then intermittently whenever you feel pain.
I highly think it may be calcaneal spur. If you have diffculty getting x ray and this blood test; you can start waering soft rubber slippers and avoid long standing and use painkillers as advised. This may improve your symptoms. And get the x ray once things are favourable.
good day

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