DOI: https://doi.org/10.21203/rs.3.rs-2179570/v1
This article reports the case of a woman with chief complains of aching pain in the upper right of her abdomen, fatigue, and weakness. She had no medical history of any diseases, trauma, and other signs related to her complains. Both blood tests and abdominal ultrasonography revealed that she has been afflicted with nonalcoholic fatty liver disease (NAFLD). The medical procedure consisted of administering a polyphenolic flavonoid named silymarin, which have been pointed out that it has antioxidant, anti-fibrotic, and anti-inflammatory properties. After taking 30 days silymarin, her liver aminotransferase enzymes levels including alanine aminotransferase (ALT) and aspartate aminotransferase (AST), which are considered criteria to diagnose NAFLD, decreased. Therefore, this result unifies this notion that silymarin can be deemed as a therapeutic agent to be used in NAFLD patients.
Nonalcoholic fatty liver disease (NAFLD) has been deemed a remarkable cause of chronic liver disease worldwide (1). It also has become one of the leading causes of cirrhosis (2) – the end stage of a wide number of chronic liver conditions in which healthy liver tissue is replaced with scar tissue, whereby the liver is permanently damaged (3).
NAFLD, in many cases, can be diagnosed via blood tests showing increased levels of the liver enzymes alanine aminotransferase test (ALT) and aspartate aminotransferase test (AST) (4, 5). This condition may also be ascertained through an abdominal ultrasonography (6).
It has been pointed out that the lifestyle modification, via diet and weight loss, has a key role to prevent complications of NAFLD (7). To date, no definite pharmacological treatment has been approved for NAFLD; however, the two best drug options affirmed to have potential impacts in NAFLD patients are vitamin E – an antioxidant (8) – and pioglitazone – a drug used to treat diabetes (9, 10).
Silymarin is a polyphenolic flavonoid derived from milk thistle – silybum marianum. It encompasses three phytochemicals such as silidianin, silybin, and silicristin (11). Silymarin, along with drugs mentioned above, has been used in the treatment of sundry liver disorders for centuries (12). Of note, silymarin can protect liver cells via a number of mechanisms; it has antioxidant (13, 14), anti-inflammatory (15), and antifibrotic properties (16–18). Silymarin also was shown to have impact on intracellular glutathione, which prevents lipoperoxidation of membranes (19). Therefore, silymarin can be deemed a therapeutic agent to treat patients suffering from nonalcoholic fatty liver disease.
Herein the case of patient with NAFLD whom her liver aminotransferase enzymes levels included AST and ALT were reduced by taking silymarin will be presented.
The case of a 58-year-old female patient with no medical history is described. Her chief complains were aching pain in the upper right side of the abdomen, severe tiredness, and weakness. She had not presented any diseases, accident, falling down, or conditions related to her complains.
Upon her admission, the following vital signs were observed: body temperature 36.5°C, blood pressure 115/75 mmHg, heart rate 70 per minute, respiratory rate 13 per minute, and oxygen saturation 98%. And also, her body mass index (BMI) was 24.44. All other examination were normal. A blood tests to check her organs and an abdominal ultrasonography were ordered. Blood tests included white blood cell count, red blood cell count, hemoglobin, platelet, fasting blood sugar, hemoglobin A1c, triglyceride, cholesterol, calcium, phosphor, and vitamin D3 ranges were, in accordance with reference range, normal. However, the levels of AST and ALT were elevated, which accounted for 45 and 53 U/L, respectively; while the reference range for both of them were defined to be up to 40 U/L. Also, abdominal ultrasonography result is given in Fig. 1.
According to having increased levels of the liver enzymes ALT and AST in blood tests, and to abdominal ultrasonography result showing grade 2 of fatty liver, it was found that she has been afflicted with NAFLD. As of diagnosis, administration of silymarin 140 mg TID (with the brand name of Livergol from Goldaru Pharmaceutical Company, Iran) was initiated; taking silymarin had been continued for 30 days. Over the period, vital signs, in particular blood pressure, of patients were evaluated, and no unstable signs was observed. Also, no adverse effect – such as nausea, diarrhea, intestinal gas, fullness or pain in the stomach, and loss of appetite which was reported in some studies (20) – of taking silymarin was reported over the period of treatment.
After 30 days of taking silymarin 140 mg TID, lab tests were ordered. As a result, the levels of AST and ALT returned to their normal range, which accounted for 14 and 17 U/L, respectively. Patient also had no complains of pain in the upper right side of her abdomen and of feeling weakness.
Nonalcoholic fatty liver disease (NAFLD), also known as metabolic associated fatty liver disease (MAFLD), is a condition in which excess fat builds up in hepatocytes (21). This buildup of fat is not caused by heavy alcohol use (22). NAFLD is the most prevalent liver condition worldwide. Even though both obesity and type 2 diabetes are deemed strong risk factors of NAFLD (23), this case had no history of obesity and type 2 diabetes. Her BMI was 24.44, which is categorized in normal weight (24).
This condition can be diagnosed via blood tests or imaging tests (25). For instance, it can be ascertained fatty liver disease if liver enzymes, ALT and AST, have been elevated or if it be shown via abdominal ultrasonography. In this case, both liver enzymes and abdominal ultrasonography showed evidence of afflicted fatty liver disease – nonalcoholic fatty liver disease.
Dietary changes and exercise culminating in weight loss have been deemed the most effective treatment for NAFLD (26–28) but still and all, there are tentative evidence that pioglitazone and vitamin E can be effective in the treatment of NAFLD patients (29, 30). In this case, a polyphenolic flavonoid – silymarin – had being administered for 30 days.
Silymarin is a natural compound that is present in species derived from Silybum marianum – which is commonly known as milk thistle. On note, silymarin has been reported to have antioxidant, anti-fibrotic, anti-proliferative, immunomodulatory, and antiviral properties. Owing to its phenolic nature, it has the ability to donate electrons to stabilize free radicals (FR) and reactive oxygen species (ROS) (31). The use of silymarin extract, in accordance with a study, in 72 patients afflicted with NAFLD on a controlled diet led to a remarkable decline in the levels of enzymes liver – alanine aminotransferase (ALT) and aspartame aminotransferase (AST) (32).
In other studies, it was found that silymarin is able to impede the entrance of toxins into the interior of liver cells, and also it provokes metabolically hepatic cells and activates the RNA iosynthesis of ribosomes to stimulate protein formation (33–35). Additionally, the impact on the reduction of ALT and AST of taking silymarin has been reported in other studies (36–39).
Although it may be found from this report that silymarin has the ability to diminish the levels of liver aminotransferase enzymes, we could reach this notion that silymarin can be treat NAFLD patients if no sign was shown in liver ultrasonography. However, it was of the faults of this study that liver ultrasonography was assessed just before starting treatment process. That is why further studies are in need to be caried out to reach a converge notion that silymarin is able to successfully treat NAFLD patients – not to mention it can be helpful as a therapeutic agent.
Who was described herein was a case with chief complains of aching pain in the upper right side of abdomen, weakness, and fatigue; she had no medical history of any other diseases. These complains was ascertained to be due to fatty liver disease. After blood tests and abdominal ultrasonography, nonalcoholic fatty liver disease was diagnosed. As of diagnosis till 30 days after, silymarin 140 mg TID (Livergol 140®) had being administered, whereby her liver aminotransferase enzymes levels included AST and ALT were diminished. And eventually, the patient was satisfied with this therapeutic method, as she reported no signs of pain, fatigue, and weakness. Hence, silymarin can be considered as a therapeutic agent to be used in NAFLD patients.
nonalcoholic fatty liver disease
alanine aminotransferase test
aspartate aminotransferase test
body mass index
metabolic associated fatty liver disease
free radicals
reactive oxygen species.
Funding: Not applicable.
Availability of Data and Materials All data and materials are within the paper.
Declarations Ethics Approval and Consent to Participate: Written informed consent was obtained from the patient for publication of this case report.
Consent for Publication: The final version of the work has been read and approved by the author.
Competing Interests: There is no conflict of interest.