Chapter 3 Fatty Liver Diseases 1 Alcoholic steatosis Case 3.1

Clinical Presentation 3 Fatty Liver Diseases 2 Clinical Presentation A 38-year-old woman presented with a 4 week history of weakness. Two weeks before presentation she became jaundiced. There was no history of IV drug use, blood transfusions, or contact with individuals who had hepatitis. She had a history of heavy alcohol intake for the past 15 years. On physical exam the liver was enlarged and she was slightly icteric, without abdominal distension or splenomegaly.

Laboratory Values Course in Hospital AST: 85 ALT: 22 Alk Phos: 210 3 Fatty Liver Diseases 3 Laboratory Values AST: 85 ALT: 22 Alk Phos: 210 Total Bilirubin/Direct: 3.5/2.6 Total Protein: 6.8 Albumin: 3.8 WBC 6000 with 58% neutrophils Serologies: HBsAg negative Course in Hospital A diagnosis of alcoholic liver disease was suspected and a liver biopsy was performed for confirmation.

Pathology 3 Fatty Liver Diseases 4 Figure 3.1(a) Figure 3.1(b) The portal tracts showed absent to minimal periportal fibrosis; absent to minimal perivenular fibrosis was present, without intraluminal fibrosis of the terminal hepatic venules (trichrome) (a). Diffuse macrovesicular steatosis was present without liver cell ballooning, Mallory-Denk body formation, or lobular inflammation (b). Figure 3.1(a) Figure 3.1(b)

3 Fatty Liver Diseases 5 Diagnosis Alcoholic steatosis

3 Fatty Liver Diseases 6 Comment In the early stages of chronic alcoholic liver disease, patients may present with non-specific signs and symptoms, with mild transaminase elevations. The biopsy may show steatosis but otherwise minimal changes, without liver cell ballooning, Mallory-Denk body formation, lobular inflammation, or sinusoidal fibrosis, these latter features seen in active alcoholic liver disease. Although this biopsy showed predominantly steatosis, even the minimal periportal and perivenular fibrosis associated with the slightly abnormal liver tests signals that a liver disease, albeit in early stage, is present that will always progress if the patient does not abstain.