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

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.

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 (betablocker) 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 (dopamine antogonist). 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 (antihistamine), 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.

Hi,

Welcome back to icliniq.com.

Thanks for sharing rest of the investigations (attachments removed for patient identity protection) 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?

Thank you.

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 (liver function test) 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.:)

Hi,

Welcome back to icliniq.com.

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.

Thank you.

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.

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.

Hi,

Welcome back to icliniq.com

FBS has a relation with HbA1c. Both are measurements of the blood sugars in the blood. FBS tell the sugars after fasting, while HbA1c shows the status for the last 3 months of average sugar levels. But both have their interpretation of the scenario.

I understand you feel the pain over your right shoulder which radiates to your right breast, This pain is accompanied by leg pain and heel pains. This pain worsens when you lie down or when you sit. You feel a strong urge to pass stools when you eat meals.

The pain you feel is because of distension of your 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 sugar. Human blood sugars have to do a lot with the gastrointestinal tract. As one such example, increased levels of sugars after a meal can cause slowing of the stomach and small bowel motility and can cause accumulation of large amounts of food within the upper part of the gastrointestinal tract with lots of gases. This can cause symptoms that you are mentioning. I suggest you divide your meals into portions. Instead of 3 to 4 regular meals in a day, divide it into 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 an hour before meals twice daily. This is a prokinetic medication that 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.

Thank you.

Hi,

Welcome back to icliniq.com.

You can say that. Diabetes and hyperlipidemia can cause blood vessel narrowing which can cause nerve damage. These disorders plus hypertension (which you do not have) are conditions that can affect the human body from 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.

Thank you.

Hi,

Welcome back to icliniq.com.

There are obvious thromboembolisms on both sides of pulmonary arteries. Maybe this causes low oxygen in the blood and hence easy fatiguability. Xeralto has been started because of this. I suggest you take advice from a pulmonologist. I may not be the best person to give you advice on this.

Thank you.

Hello,

Welcome back to icliniq.com

I know I have suggested CPK and also have seen this report earlier (attachments removed for patient identity protection). 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 the range of thousands, which it is not. The upper limit of the normal can simply be due to many reasons; a few common of those are just above average or strenuous exercise the day before the test; even an intravenous and intramuscular injection can increase the CPK in some hundreds. 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 continuous pain I suggest you check your vitamin D level.

Plus to rule out another possibility of the calcaneal spur, which is a bony projection from one of the bones of the feet. It can cause pain, severe at times and usually present when walking. This can easily 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 have drug side effects. The common of which is Carveda. I suggest you discuss with your physician for consideration of reducing the dose or stopping it and see if it improves your symptoms.

For your pain, I suggest you start tablet Nuberol forte (Orphenadrine plus Paracetamol ) thrice daily for three days and then intermittently whenever you feel pain.

I highly think it may be a calcaneal spur. If you have difficulty getting an X-ray and this blood test, you can start wearing soft rubber slippers avoid long standing and use painkillers as advised. This may improve your symptoms. And get the X-ray once things are favourable.

Thank you.

Hello,

Welcome back to icliniq.com.

Your vitamin D levels are good.

Did you see some improvement in your heel pain?

If you feel comfort in your pain I suggest you continue with it. Do not stop. And plan for an X-ray of the heel lateral view both right and left in the near future.

Thank you.

Hi,

Welcome back to icliniq.com.

I can see there are many brands available in your place with the generic Levosulpiride.

Tablet V Pride 25 or 50 mg (this has to be taken 25 mg thrice daily half hour before meals) or Leepride 50 mg (you can take it twice daily half hour before meals) or Enteric coated SR (sustained release Levosulpiride 75 mg). Once daily half an hour before meals. Try searching for these in your nearby pharmacy. If you are still unable to find this, then take the tablet Metoclopramide 40 mg sustained release half an hour before meals.

If the sustained release is not available then you can buy Metoclopramide 10 mg tablet and take it thrice daily half an hour before meals. Both compounds Levosulpiride and Metoclopramide are prokinetic medications that will improve stomach movement. Disipal 50mg take this twice daily.

If you still have difficulty finding this brand in the market then consider purchasing the tablet Tizanidine 2 mg once daily twice daily. These both are for muscle pains. These are common medications, and can easily be purchased over the counter.

Your symptoms will improve once you start these medicines. I also asked you to take a capsule of Esomeprazole 40 mg half an hour before meals. I also want to know, were you able to discuss the problem of your shortness of breath and easy fatigue with a pulmonologist? And were you able to talk to your physician who has suggested you Carvedilol?

Thank you.

Hi,

Welcome back to icliniq.com.

I hope now thing are good to go. I really hope that I would be listening much improvement from your side in a week or two. Stay safe and take care. Thank you.