CASE 102: 48-Year-Old man with nausea and

weakness

History

• This 48-year-old man, a self-confessed alcoholic, was admitted to the hospital with chief complaints of nausea and weakness and gradually increasing abdominal girth. The patient admitted to drinking one quart of gin per day (had for the past 10 years), was unemployed and divorced. He had been to numerous institutions to try to “kick the habit”, but had not been able to abstain from alcohol for more than a couple of weeks at a time. He was disoriented and a detailed history was not possible

PE• A disoriented man appearing older than 47. B P 130/84; pulse 96 &

regular; resp 24/min

• HEENT: PERRLA, nose Ok, ears: TM intact, teeth in poor repair, tongue movements normal

• Neck: supple, no masses or bruits

• Chest: spiders on anterior chest, asymmetric gynecomastia , no rales or rhonchi, no consolidation

• Heart: normal size, no murmurs no gallop,

• Abdomen: Diffuse tenderness, esp in rt upper quadrant. Liver span 22 cm , edge very tender, spleen palpated, possible fluid wave. BS (bowel sounds) present.

• Rectal: prostate nodular, soft and enlarged, thick gooey black stool returned on glove

• Genitals: WNL

• Extremities: Pulses equal bilaterally, loss of hair mid calf

• Neuro: Cranial nerves grossly intact but couldn’t test gait, reflexes hyperactive.

• What is your initial problem list and differential?

• What lab work or procedures would you what to do now?

labsHgb: 9.0 g/dL

• Hct: 24%• MCV: 105 fL • WBC: 16.0 x 103/ L • Diff.: Segs: 70%• Bands: 10%

Lymphs: 15%• Monos 5%• Platelets: 87,000 um3

• Urinalysis:• Spec. gravity: 1.010• Bile: 2+• Chemistry:• BUN: - 35 mg/dL• Creatinine: - 1.6 mg/dL• AST: - 150 IU/L• ALT: - 110 IU/L• Alkaline Phos: - 240 IU/L• Fecal examination for blood: 4+

• Write a problem list and differential.

• Why was the patient anemic on admission?

• What is the WBC count elevated?

• Explain the enzyme findings.

Hospital Course

• The patient was admitted and closely monitored. During the evening, he vomited up a large amount of fresh blood and became unconscious. Endoscopic examination of the stomach revealed ruptured esophageal varices and diffuse oozing from the entire gastric mucosa. Attempts to control the bleeding were unsuccessful, and the patient died despite massive transfusions (32 units of RBC’s, 12 units of FEP, and 2 platelet units (single donor-apheresis).

Autopsy Findings

Esophageal Varices

Autopsy Findings

The liver and spleen-- note nodularity of the liver and Huge spleen (wt: 800 gram)

Normal liver

Normal weight: 1400 gms.

cut section of the liver

Normal for comparison

Low power-trichrome stain-broad bands of fibrous tissue-(blue)

Normal liver

What are Mallory Bodies

Define cirrhosis of the liver. List the signs and causes of cirrhosis.

• What is portal hypertension? List signs and causes of portal hypertension.

• Define ascites. What are some common causes?

• Define fatty change (steatosis) of the liver. Discuss the pathogenic mechanisms of fatty change. Which one is predominant in alcoholic liver disease?