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.