Alcoholic hepatitis with diffuse interstitial fibrosis Chapter 3 Fatty Liver Diseases 1 Alcoholic hepatitis with diffuse interstitial fibrosis Case 3.4

Clinical Presentation 3 Fatty Liver Diseases 2 Clinical Presentation A 45-year-old woman presented with right upper quadrant pain. The family also noted that she was jaundiced the past 1–2 months. The patient gave a history of chronic alcoholism and had started drinking at age 23. She drinks about three mini-bottles of tequila and several beers daily. Physical exam revealed hepatomegaly without a bruit, and the presence of spiders and palmar erythema. CT of the abdomen revealed a low attenuated lesion in the right lobe, felt to be an abscess and possibly related to a urinary tract infection (urine grew out 100,000 E. coli).

Laboratory Values Course in Hospital AST: 251 Total Protein: 5.2 3 Fatty Liver Diseases 3 Laboratory Values AST: 251 ALT: 19 Alk Phos: 227 Total Bilirubin: 2.1 Total Protein: 5.2 Albumin: 2.2 Elevated WBC count Serologies: HBsAg, anti-HCV: Negative Course in Hospital Alcoholic hepatitis was suspected and a liver biopsy was performed to confirm the diagnosis and rule out infection.

3 Fatty Liver Diseases 4 Pathology Portal and extensive diffuse sinusoidal collagen deposition was present with involvement of all zones in all lobules (trichrome) (a), without distinct regenerative nodule formation. Steatosis, liver cell ballooning, Mallory-Denk body formation, and lobular lymphocytic and neutrophilic infiltrates were present (b). Figure 3.4(a) Figure 3.4(b)

Alcoholic hepatitis with diffuse interstitial fibrosis 3 Fatty Liver Diseases 5 Diagnosis Alcoholic hepatitis with diffuse interstitial fibrosis

3 Fatty Liver Diseases 6 Comment Although alcoholic hepatitis is associated with sinusoidal collagen deposition that is most pronounced in the perivenular zones, at times the degree can be striking and diffuse, involving all zones in all lobes (“diffuse interstitial fibrosis”). These patients on biopsy do not have distinct regenerative nodules for a diagnosis of cirrhosis, yet may have all the clinical signs and symptoms as well as laboratory tests of an advanced cirrhosis. Sometimes these patients may have major complications of portal hypertension such as intractable ascites. Chronic alcoholics with advanced liver disease also are more likely to suffer from other factors that include infections, bacteremia, spontaneous bacterial peritonitis, pneumonia, and urinary tract infections (the latter occurring in this present case) due to a number of factors including poor nourishment and impaired immune responses.