Alcoholic foamy degeneration with early alcoholic cirrhosis Chapter 3 Fatty Liver Diseases 1 Alcoholic foamy degeneration with early alcoholic cirrhosis Case 3.9

Clinical Presentation 3 Fatty Liver Diseases 2 Clinical Presentation A 35-year-old man presented with a 3 day history of jaundice, pale stools, and dark urine. He had a history of chronic alcoholism for 4 years, drinking almost daily, and had his last drink the day before admission. Prominent hepatomegaly was present with the liver firm. A positive hepatic bruit and 1+ pitting edema were present. Ultrasound revealed a fatty liver with a nodular liver surface, ascites, and recanalization of the periumbilical vein.

Laboratory Values Course in Hospital AST: 337 ALT: 129 Alk Phos: 344 Fatty Liver Diseases 3 Laboratory Values AST: 337 ALT: 129 Alk Phos: 344 Total Bilirubin: 17.3 Total Protein: 5.9 Albumin: 3.0 WBC: 9600 Serologies: HBsAg, anti-HCV: Negative Course in Hospital He was assessed as having alcoholic hepatitis although alcoholic foamy degenerate (AFD) was also suspected due to the prominent hepatomegaly and fatty change seen on ultrasound, and a liver biopsy was performed.

Pathology 3 Fatty Liver Diseases 4 Portal and perivenular bridging fibrosis with early cirrhosis was present. The hepatocytes showed diffuse 4+ steatosis with microvesicular “foamy” change of many of the perivenular hepatocytes (a, b). Cholestasis was present, but there was minimal inflammation and no evidence of liver cell ballooning or Mallory-Denk body formation. Figure 3.9(a) Figure 3.9(b)

3 Fatty Liver Diseases 5 Diagnosis Alcoholic foamy degeneration (AFD) with early alcoholic cirrhosis

3 Fatty Liver Diseases 6 Comment The combination of the AST in the mid-300s with elevated alkaline phosphatase and a fatty liver on ultrasound entered AFD into the differential in a patient with otherwise classic alcoholic hepatitis. In this case example there was no coexisting changes of classic alcoholic hepatitis (liver cell ballooning, Mallory-Denk body formation). The fact that the patient had cirrhosis after only a four year history of chronic alcoholism is somewhat unusual, although obtaining an accurate history from chronic alcoholic patients is oftentimes a challenge, and participation of family members in history taking is oftentimes essential.