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Narrative Review: Hepatobiliary Disease in Type 2 Diabetes Mellitus

Keith G. Tolman, MD; Vivian Fonseca, MD; Meng H. Tan, MD; and Anthony Dalpiaz, PharmD
[+] Article, Author, and Disclosure Information

From University of Utah and University Hospitals and Clinics, Salt Lake City, Utah; Tulane University, New Orleans, Louisiana; and Eli Lilly and Company, Indianapolis, Indiana.

Acknowledgments: The authors thank Rowan Tweedale for editorial support and Judy Summerhays for secretarial support.

Potential Financial Conflicts of Interest:Employment: M.H. Tan (Eli Lilly); Consultancies: K.G. Tolman (Takeda, Eli Lilly), V. Fonseca (Eli Lilly, Takeda, GlaxoSmithKline, Pfizer, Aventis); Honoraria: K.G. Tolman (Takeda, Eli Lilly), V. Fonseca (Eli Lilly, Takeda, GlaxoSmithKline, Pfizer, Aventis); Stock ownership or options (other than mutual funds): M.H. Tan (Eli Lilly); Grants received: V. Fonseca (Eli Lilly, Takeda, GlaxoSmithKline, Pfizer, Aventis).

Requests for Single Reprints: Keith G. Tolman, MD, Department of Internal Medicine, University of Utah School of Medicine, 30 North 1900 East, Salt Lake City, UT 84132; e-mail, keith.tolman@hsc.utah.edu.

Current Author Addresses: Dr. Tolman: Division of Gastroenterology, University of Utah, 30 N 1900 E, RM 4R118, Salt Lake City, UT 84132.

Dr. Fonseca: 1430 Tulane Avenue, SL 53, New Orleans, LA 70112.

Dr. Tan: Eli Lilly and Company, Lilly Corporate Center, Indianapolis, IN 46285.

Dr. Dalpiaz: Department of Pharmacy, University of Utah, 30 N 1900 E, Salt Lake City, UT 84132.

Ann Intern Med. 2004;141(12):946-956. doi:10.7326/0003-4819-141-12-200412210-00011
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Diabetes mellitus is the fifth leading cause of death in the United States; 17 million people are affected. Liver disease is one of the leading causes of death in persons with type 2 diabetes. The standardized mortality rate for death from liver disease is greater than that for cardiovascular disease. The spectrum of liver disease in type 2 diabetes ranges from nonalcoholic fatty liver disease to cirrhosis and hepatocellular carcinoma. The incidence of hepatitis C and acute liver failure is also increased. Nonalcoholic fatty liver disease is now considered part of the metabolic syndrome, and, with alcohol and hepatitis C, is the most common cause of chronic liver disease in the United States. Weight reduction and exercise are the mainstays of treatment for nonalcoholic fatty liver disease, but there are promising results with the new thiazolidinediones (pioglitazone and rosiglitazone) as well as metformin and 3-hydroxy-3-methylglutaryl coenzyme A inhibitors.


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Figure 1.
Some metabolic effects of insulin resistance in skeletal muscle, fat, and liver.

FFA = free fatty acid; VLDL = very-low-density lipoprotein.

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Figure 2.
Ultrasonographic findings from a patient with steatosis.

Top. Fatty liver showing a so-called “bright liver.” Bottom. The dark areas appear as masses and represent areas of liver that are spared from fatty infiltration—the so-called “phantom tumor.”

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Figure 3.
Liver biopsy specimens from persons with steatohepatitis.

Top. Liver biopsy specimen showing fatty infiltration with so-called chicken-wire appearance. Bottom. Liver biopsy specimen showing fatty liver with accompanying inflammatory infiltrate and fibrosis (nonalcoholic steatohepatitis). (Hematoxylin–eosin stain; original magnification, ×40.)

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Emphysematous Cholecystitis
Posted on January 2, 2005
Ajit S Kashyap
Command Hospital (Southern Command),Pune 411 040,India
Conflict of Interest: None Declared

sir, We read with interest the excellent review on hepatobiliary diseases in Type 2 DM (1). However authors do not include emphysematous cholecytitis in hepatobiliary diseases in Type 2 DM.

Emphysematous cholecystitis is a highly virulent form of acute cholecystitis characterised by gas production in and around the gall bladder. It is caused by anaerobes clostridium species- welchii and perferingens (46%), aerobic organisms being Escherichia coli (33%), staphylococci, streptococci, and pseudomonas. Emphysematous cholecystitis occurs much more commonly in patients with diabetes, with approximately 35% of all cases involving diabetics(2,3,4). Diabetic vascular disease is thought to play a primary role in the pathogenesis of emphysematous cholecystitis. Narrowing of gallbladder arterioles has been frequently observed on histopathology of surgical specimens, and may lead to arterial insufficiency and ischemia of gallbladder wall. Ischemia creates an anaerobic environment conducive to gas production (2). Morbidity and mortality in this entity is much higher than in other forms of cholecystitis (2,3,4). References 1. Tolman KG, Fonseca V, Tan MH, Dalpiaz D. Narrative review: Hepatobiliary disease in Type 2 Diabetes Mellitus. Ann Intern Med. 2004;141:946-956. 2.Smitherman KO, Peacock Jr. JE. Infectious emergencies in patients with diabetes mellitus.Med Clin North Am. 1995;79: 53-77. 3.Greenberger NJ, Paumgartner G. Diseases of the gallbladder and bile ducts. In :Kasper DL, Fauci AS, Longo DL, Et al. Eds. Harrison's principles of internal medicine. 16th Ed. VolII. McGraw-Hill: New York. 2005:1880-1891. 4.Kasper DL, Madoff LC. Gas gangrene and other clostridial infections.In :Kasper DL, Fauci AS, Longo DL, etal. Eds. Harrison's principles of internal medicine. 16th Ed. VolI. McGraw-Hill: New York. 2005:845-849.

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