Differentials
Chronic liver disease
SIGNS / SYMPTOMS
Presence of stigmata of chronic liver disease (e.g., spider angioma, telangiectasia, collateral circulation of the abdominal wall around the umbilicus).
Other clinical features include jaundice, hepatosplenomegaly, abdominal distension, and ascites.
INVESTIGATIONS
Liver function tests: elevated alanine aminotransferase and aspartate aminotransferase.
Gamma glutamyl transferase: may be elevated.
Serum albumin and sodium: reduced.
Prothrombin time: prolonged.
Platelet count: reduced.
Bilirubin: may be elevated.
Cushing syndrome
SIGNS / SYMPTOMS
Signs of hypercortisolism: central obesity, plethoric "moon face," "buffalo hump," acne, purple striae.
INVESTIGATIONS
Serum cortisol (morning and midnight samples): elevated, loss of diurnal rhythm.
Urinary cortisol: elevated.
Overnight suppression test: no suppression of morning (8 a.m.) cortisol levels after taking 1 mg dexamethasone (11 p.m.) the previous night (48-hour suppression test with 0.5 mg dexamethasone every 6 hours is an alternative).
Late-night salivary cortisol: elevated.
Patients with an abnormal result should undergo a second test, or a serum midnight cortisol or dexamethasone/corticotropin-releasing hormone test.[75]
Congenital adrenal hyperplasia
SIGNS / SYMPTOMS
Associated with obesity, insulin resistance, and hypertension with additional signs of hyperandrogenism (genital ambiguity in females, precocious puberty in males). Rarely, signs and symptoms of salt loss including hypotension may be present.
If undiagnosed and untreated, may progress to a life-threatening adrenal crisis with vomiting, diarrhea, hypoglycemia, hypovolemia, and shock.
INVESTIGATIONS
17-hydroxyprogesterone levels: elevated.[76]
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