Diagnostic challenges of clinically significant portal hypertension in geriatric metabolic dysfunction-associated fatty liver disease: A case report

Table 1 Clinical timeline and key findings of the patient

Time	Clinical events and findings
4 years before admission	The patient experienced recurrent upper abdominal discomfort and bloating. Abdominal CT showed chronic liver disease with fatty changes, splenomegaly, and splenic vein dilatation. Endoscopy revealed portal hypertensive gastropathy and multiple gastric ulcers without prior bleeding
3 days before admission	The patient developed hematemesis and melena
Day 0 (admission)	Stable hemodynamics, BMI 30.5 kg/m2. Presented with pallor, epigastric tenderness, splenomegaly, and minimal ascites. Laboratory tests revealed anemia, thrombocytopenia, hypoalbuminemia, prolonged prothrombin time, impaired liver function, and hyperglycemia. Viral hepatitis markers were negative
During hospitalization	Abdominal ultrasound showed features of chronic liver disease, splenomegaly, and multiple gallstones. CT confirmed moderate diffuse hepatic steatosis, splenic vein dilatation, and splenomegaly. Upper GI endoscopy demonstrated grade II-III esophageal varices and moderate portal hypertensive gastropathy. FibroScan (E = 28 kPa; CAP = 191 dB/m) and noninvasive fibrosis scores (NFS, APRI, FIB-4) indicated advanced fibrosis (METAVIR F4)
Treatment phase	Endoscopic variceal ligation at five sites. Received carvedilol 12.5 mg once daily, rosuvastatin 10 mg once daily, empagliflozin 75 mg once daily, long-acting insulin glargine 10 units daily, a proton pump inhibitor, and a mucous protector lifestyle modifications were also initiated
2-week follow-up	Clinical improvement noted with resolution of abdominal pain, vomiting, and bloating. No recurrent bleeding was observed. The patient remained stable on follow-up

CT: Computed tomography; GI: Gastrointestinal; NFS: Non-alcoholic fatty liver disease fibrosis score; APRI: Aspartate aminotransferase to platelet ratio index; FIB-4: Fibrosis-4 index; BMI: Body mass index; CAP: Controlled attenuation parameter.