Young adult with NASH

A 44-year-old male was admitted to hospital after experiencing hematemesis caused by the rupture of gastroesophageal varices. He had no significant prior medical or family history of liver diseases, and he was not a regular drinker or using drugs. Two years before his admission, his height was 172.2 cm, his body weight was 120.1 kg, and his BMI was 40.5 kg/m2. When he was admitted, his body weight had decreased to 116.7 kg, and his BMI was 39.4 kg/m2. The physical examination revealed mild anemia in the palpebral conjunctiva and hepatosplenomegaly. Laboratory data showed an elevated WBC (15,100/mm3) and a normal platelet count (18.3 × 104/µL). However, his Hb level was low at 7.0 g/dL due to bleeding. Biochemical examination indicated normal levels of serum total bilirubin (0.8 mg/dL), albumin (2.9 g/dL), aspartate aminotransferase (19 U/L), alanine aminotransferase (18 U/L), alkaline phosphatase (135 U/L), and gamma-glutamic transpeptidase (65 U/L). C-reactive protein was slightly elevated (1.33 mg/dL). Fibrosis markers, including hyaluronic acid, type 4 collagen, and Mac2-binding protein, increased. However, the aspartate aminotransferase to platelet ratio index (APRI) and the fibrosis-4 index were not elevated, suggesting that advanced liver cirrhosis was less likely. Further tests for viral hepatitis, autoimmune hepatitis, and other liver diseases were negative, except for an elevated antinuclear antibody. The patient had abnormal glucose metabolism with high HbA1c, glycoalbumin, fasting plasma glucose levels, and elevated insulin resistance markers. Additionally, the patient was advised to undergo abdominal ultrasonography, contrast-enhanced CT, esophagogastroduodenoscopy (EGD), and histological evaluations.