Pathology · Year 2 · from Pathology
Case 2: Chronic Alcoholic Liver Disease with Cirrhosis
Patient Demographics
- Age: 52 years old
- Sex: Male
- Occupation: Unemployed (former bartender)
Chief Complaint
"Swollen belly and yellow skin for 3 weeks"
History of Present Illness
A 52-year-old male presents with progressive abdominal distension and yellowing of his skin and eyes over the past 3 weeks. He reports increasing fatigue, easy bruising, and poor appetite. He has a long history of alcohol abuse, drinking approximately 8-10 beers daily for the past 25 years, with occasional whiskey binges. He had one previous hospitalization for "liver problems" 2 years ago but continued drinking. He denies IV drug use but has multiple tattoos from his youth. He has noted confusion at times and difficulty concentrating.
Physical Examination
- Vital Signs: BP 102/64 mmHg, HR 92 bpm, RR 18/min, Temp 37.8C
- General: Cachectic male with temporal wasting, jaundice, fetor hepaticus
- HEENT: Icteric sclerae, parotid enlargement
- Chest: Gynecomastia, spider angiomata on chest
- Abdomen: Distended with tense ascites, shifting dullness positive, splenomegaly, caput medusae
- Extremities: Palmar erythema, bilateral pitting edema, muscle wasting
- Neurologic: Asterixis present, mild confusion
Diagnostic Workup
Laboratory Studies:
| Test | Result | Reference Range |
|---|---|---|
| AST | 145 U/L | 10-40 U/L |
| ALT | 62 U/L | 7-56 U/L |
| AST:ALT ratio | 2.3:1 | - |
| GGT | 485 U/L | 8-61 U/L |
| Total bilirubin | 8.5 mg/dL | 0.1-1.2 mg/dL |
| Albumin | 2.1 g/dL | 3.5-5.5 g/dL |
| INR | 2.1 | 0.8-1.2 |
| Platelets | 68,000/uL | 150,000-400,000/uL |
| Sodium | 128 mEq/L | 136-145 mEq/L |
| Ammonia | 85 umol/L | 15-45 umol/L |
Imaging:
- Ultrasound with Doppler: Nodular liver contour, splenomegaly (16 cm), patent portal vein with slow hepatofugal flow, moderate ascites
- CT Abdomen: Cirrhotic liver, large esophageal varices, splenomegaly, ascites
Paracentesis:
- SAAG: 1.8 (>1.1 consistent with portal hypertension)
- Total protein: 1.2 g/dL
- Cell count: WBC 180/uL, PMN 45/uL (rules out SBP)
- Negative cultures
Pathology Correlation
This case demonstrates the spectrum of alcoholic liver disease:
Stages of Alcoholic Liver Disease:
1. Alcoholic Steatosis (Fatty Liver):
- Mechanism: Alcohol metabolism via alcohol dehydrogenase generates excess NADH
- NADH accumulation shifts metabolism toward lipid synthesis, inhibits fatty acid oxidation
- Macrovesicular steatosis - large fat droplets displacing nucleus
- Completely reversible with abstinence
2. Alcoholic Hepatitis:
- Mallory-Denk bodies (Mallory hyaline) - eosinophilic cytoplasmic inclusions of ubiquitinated cytokeratin
- Ballooning degeneration - swollen hepatocytes
- Neutrophilic infiltration - satellitosis (neutrophils surrounding damaged hepatocytes)
- AST:ALT ratio >2:1 - characteristic of alcoholic liver disease (alcohol inhibits ALT more than AST)
3. Cirrhosis:
- End-stage of chronic liver injury
- Regenerative nodules surrounded by fibrous septa
- Loss of normal lobular architecture
- Irreversible
Complications of Cirrhosis (Portal Hypertension):
- Ascites: Increased sinusoidal pressure + hypoalbuminemia
- Esophageal varices: Porto-systemic shunting
- Hepatic encephalopathy: Ammonia bypasses liver
- Coagulopathy: Decreased clotting factor synthesis
- Hepatorenal syndrome: Renal vasoconstriction
Clinical Image
Gross pathology of cirrhotic liver demonstrating the characteristic nodular surface. The liver shows regenerative nodules of varying sizes separated by fibrous septa, representing end-stage chronic liver disease.
Image Source: Wikimedia Commons - "Liver cirrhosis" License: CC BY-SA 3.0 URL: https://commons.wikimedia.org/wiki/File:Hepatocellular_carcinoma_1.jpg
Diagnosis
- Decompensated Alcoholic Cirrhosis
- Child-Pugh Score: C (10 points - severe)
- MELD Score: 24 (high mortality without transplant)
- Portal Hypertension with ascites and varices
- Hepatic Encephalopathy (grade 2)
Treatment
Immediate:
- NPO, IV fluids
- Lactulose for hepatic encephalopathy
- Rifaximin (reduces ammonia-producing bacteria)
- Albumin infusion
- Sodium and fluid restriction for ascites
Long-term:
- Absolute alcohol abstinence - essential
- Diuretics (spironolactone + furosemide) for ascites
- Beta-blocker for variceal bleeding prophylaxis
- Nutritional support with protein supplementation
- Liver transplant evaluation (requires 6 months abstinence)
- Hepatocellular carcinoma surveillance (ultrasound every 6 months)
Teaching Points
- Alcoholic liver disease progresses from steatosis to hepatitis to cirrhosis
- AST:ALT ratio >2:1 is characteristic (due to mitochondrial AST release and pyridoxine deficiency)
- Mallory-Denk bodies are characteristic but not pathognomonic for alcoholic hepatitis
- Portal hypertension causes most complications: ascites, varices, encephalopathy
- MELD score predicts mortality and prioritizes transplant listing
- Steatosis is reversible with abstinence; cirrhosis is not