Transcript Case 570 42 YEAR-OLD MAN WITH ABDOMINAL DISTENTION

Case 570 42 YEAR-OLD MAN
WITH ABDOMINAL
DISTENTION
History

A 42-year-old man presents with abdominal
distention and discomfort. He has a long
history of alcohol use and intravenous drug
use. He is known to be hepatitis C antibody
positive. He has been abstinent from alcohol
for the past eight months. He also complains
of mild, low-grade fevers. He is currently
employed, married and has 2 teenage children
PE








40 year-old man appearing older than stated age. P: 88/min, BP: 130/80, Resp:
16/min. Temp: 100 F.
HEENT: sclera slightly yellow PERRLA, mouth-WNL
Neck: supple
Chest: clear to A&P
Heart: PMI at midclavicular line, regular rate-grade II/VI systolic murmur at apex.
Abdomen: distended. Increased prominence of the abdominal collateral vessels is
noted. Bulging flanks are appreciated. Shifting dullness is demonstrated. Liver
edge is palpable 2 cm below the costal margin. No spleen is palpable. Mild
diffuse tenderness is noted. No guarding is noted. Rectal-no stool returned,
prostate normal,
Skin-slight yellowish twinge, a few spider angiomata noted on chest, some palmer
erythema, Extremities-WNL
Neurologic-general hyperactive reflexes, cranial nerves I-XII grossly intact.
Basic lab











• WBC: 8.7x103/uL
Hematocrit: 30% Hgb: 11 g/dL, MCV 85 fL, platelet
3
count: 90 x 10 /uL
Prothrombin time-18 seconds, aptt 38 sec.
•
Aspartate Transferase, (AST): 90 IU/L
Alanine Amino Transferase, (ALT): 22IU/L
Albumin - 2.8 g/dL
Na: 136 mmol/L
K: 4.5 mmol/L
Cl: 98 mmol/L
HCO3: 20 mmol/L
BUN: 28 mg/dL
Creatinine: 1.8 mg/dL
Glucose: 106 mg/dL
A paracentesis was done: studies on the fluid showed: 2 L removed, serous (yellow) clear
fluid, 650 polymorphonuclear cells, albumin 0.5 g/dL, amylase 30 mg/dL, and culture
negative.
Microscopic photo of the liver at the time of the present admission. – note
the broad bands of fibrosis – little steatosis at this time There is a fair
amount of chronic inflammation in the fibrous areas – no lobular hepatitis
is seen
A closer look at the portal area
This is a photo from this patient’s liver biopsy done 5 years prior
to his transplant. Note the massive macro-steatosis (the clear
spaces in the hepatocytes) and early bridging fibrosis (blue
areas).
High power showing “alcoholic hepatitis” –note cellular
disarray, ballooning degeneration, neutrophilic infiltrate,
Mallroy bodies
Another field from this biopsy showing Mallroy body (Hyalin in a
cell with a viable nucleus) and a Councilman body (eosinophilic
round mass without a nucleus)
More history

This patient eventually recovered (fever went
away and less discomfort) with antibiotics.
He was placed on a diuretic and low salt diet.
He remained alcohol abstinent for the next
three months. He then suffered a lifethreatening GI hemorrhage secondary to
varices. These were sclerosed. He was
referred for liver transplantation.
Gross photo of the liver removed at transplantation-note
nodular pattern. The liver is very firm – a normal liver one
can easily put your fingers through a 1-cm. thick slide, but
not in this case.