Question

Mr. V is a 55-year-old alcoholic who checked into a clinic, complaining that he has been experiencing a persistent cough and feeling more fatigued, nauseous, and irritable. In addition, he is experiencing more frequent memory lapses. His stomach is distended, but on palpation, his liver is small in size and firm, indicating cirrhosis. Lab tests indicate a decrease in hemoglobin, albumin, and prothrombin levels with elevated serum bilirubin and ammonia levels.

1. Describe the various stages through which Mr. V’s liver has progressed and the implications of the current stage. (See Cirrhosis—Alcoholic Liver Disease.)

2. Provide a specific rationale for each of Mr. V’s manifestations and blood values. (See Alcoholic Liver Disease—Pathophysiology, Signs and Symptoms.)

3. a. Is it possible to reverse the damage to the liver at this stage? What is the prognosis? b. Choose four significant complications that are likely to occur, and discuss the predisposing factors and effects on the liver. (See Pathophysiology and Treatment.)

Answer 1

ANSWER 1) Alcoholic liver disease is a medical condition resulting due to overuse of alcohol, including fatty liver, alcoholic or chronic hepatitis with fibrosis or cirrhosis. Liver is the organ in buman body which is responsible for majority of the detoxification activities. 80% of the alcohol passess through the liver for detoxification. The overconsumption of alcohol results in secretion of pro-inflammatory cytokines, oxidative stress, lipid peroxidation, and acetyldehyde toxicity. All these factors causes inflammation and apoptosisand evetually fibrosis of liver cells.

Alcohol gets metabolized into alcohol dehydrogenase and then to acetyldehyde. This acetyldehyde is responsible for alcohol induced fibrosis by stimulating collagen deposition by hepatic stellate cells. This increases the fibrosis and impedes the hepatic blood flow. Thus the entire hepatocyte structure is derranged

ANSWER 2)The symptoms of nausea, fatigue,irritability and memory loss is due to the accumulation of toxic substances in the blood that effects the function of brain.

The size of liver is initially enlarged due to inflammation but later with the progression of the disease, due to scar formation, the liver is smaller in size and firm.

The level of albumin is declined as its mainly produced by liver, with the reduction in the synthetic function of liver albumin level will also reduce.  Spleenomegaly which is caused by portal hypertension results in hemolysis of bloodc cells thus the patient have low hemoglobin. Liver is responsible to produce certain clotting factors and anticoagulant factor i.e prothrombin is reduced due to diminshed production by liver.

Increased bilirubin levels are due to obstruction caused by the inflammation of the liver cells which causes accumulation of bile in liver. The levels of ammonia is increased as ammonia is the byproduct of nitrogen containing compounds which is eliminated by the liver. The failure of liver to detoxify this waste products results in increases ammonia in blood.

ANSWER 3) Once the liver is cirrhosed, it is not possible to reverse the damage. Cirrhosis is an irreversible damage to liver. The prognosis of patient is poor as the patient have started showing neurological symptoms. Only symptomatic treatment can be given or the patient should undergo a liver transplant.

Cirrhosis of liver may result in following complications:

1. Ascites and edema: In liver cirrhosis, the kidneys tend to retain salt and water which results in accumulation of fluid in different areas of the body. Initially its seen in ankkles and legs usually called pitting edema that increases due to gravity by the end of the day. As the conditions worsen, the fluid gets accumulated in the abdominal cavity called ascites resulting in abdominal discomfort, breathing difficulty and weight gain. The scarring of liver increases the pressure in the liver blood vessel which may result in forcing fluid in the lining of the abdominal cavity.
2. Spontaneous bacterial peritonitis: Normally the bacteria that enters the abdominen is killed by our defense mechanism and by the liver if it enters the portal system. During cirrhosis as the abdominal cavity is filled with the ascitic fluid, it serves as a good medium for growth of bacteria and moreover, the liver cannot do anything to kill this bacteria. This result in infection and causes bacterial peritonitis. Its a life threathening complications manifested with fever, abdominal pain,diarrhea and worsening ascites.
3. Bleeding from esophageal varices: Liver cirrhosis results in increase of portal vein pressure due to obstruction in the blood flow from intestines to heart. Due to this increased blood flow and pressure , the veins in the lower esophagus anad upper part of stomach expands which is reffered as esophageal or gastric varices. The higher the pressure, bigger is the varices and more likely to bleed. The symptoms of bleeding varices include vomiting blood, malena, orthostatic hypotension, dizziness.