Alcoholic Liver Disease

Alcoholic Liver Disease

Case History • A 57year old male was admitted 14/02/99 at 1.45pm with difficulty in breathing and cough. He had been on Adalat for Hypertension and Diabetes tablets one day for the past 2 years. Patient drinks 4-5 bottles of beer and 2-3 tots of whisky daily. He also smoked. • The BP on admission was 120/90. At 3.20pm-4.45pm he developed wheezing. Chest X-Ray showed left pleural effusion and mediastinal shift. He had not passed urine. • He was mildly jaundice, with bilateral pitting edema. There was gross abdominal distension. A number of spider naevi were

vestigations done at admission showed: Parameter

Result

Normal Range

Comment

Hb

9.3 mg/dl

13.5-17.5 g/dl

Decreased

WBC

2800 x 109 /L

Platelets

300x 109/L

4.0-11.0 x 109 /L Greatly 150-400 x 109/L Increased Normal

Neutrophils

44%

60-80%

Decreased

Lymphocytes

54%

20-40%

Raised

Monocytes

2%

2-8%

Normal

MCV

104.5fL

80-96fL

Increased

ESR

51mm/h

1-10mm/h

Raised

Blood sugar

12.2mmol/L

3.5-6.0mmol/L

Raised

Liver function tests Total Bilirubin

83.4mol/L

Alkaline phosphatase SGOT

278 U/L

39-117 U/L

Raised

71U/l

12-39 U/L

Raised

SGPT

76U/L

<40 U/L

Raised

γGT

1.20 U/L

<58 U/L

The electrolytes were normal. The patient while in ward became increasingly confused, had a bout of hematemesis and died.

Clinical Diagnosis Liver Cirrhosis – Evidenced by: – Deranged LFTs. – Clinically: jaundice, ascites, edema, spider naevi Complications of Liver cirrhosis present were: Variceal bleeding. Pleural effusion. Hepatic encephalopathy.

My task To discuss the autopsy findings, cause and mechanism of death.

Introduction Main pathology Liver cirrhosis secondary to Alcoholic liver disease. Expected pathology In other systems due to: • Smoking. • Hypertension. • Diabetes. • Other effects of ethanol.

Smoking One ml of mainstream smoke has more than 4000 constituents, including 43 known carcinogens. The greatest number of deaths attributable to cigarette smoking are due to • lung cancer, • ischemic heart disease, and • chronic obstructive lung disease

Systems affected by smoking System

Effect

Respiratory System

COPD, Ca Larynx, Ca Lung

Cardiovascular

Atherosclerosis, MI

GIT

Oral lesions, Peptic ulcer disease; GERD; Pancreatitis

Renal

Ca Bladder

Diabetes and Hypertension • Their causes are multi-factorial. • When present together, they worsen condition. • HTN accelerates complication of DM e.g CVD and nephropathy. • All systems are involved.

Other systemic effects System

Diabetes Effect

Cardiovascular

Atherosclerosis

Hypertension Effect Atherosclerosis,

Nervous Sym

Neuropathy

Hypertensive heart disease Cerebrovascular

Renal

Nephropathy then ESRD GI dysfunction

accidents Arteritis, nephrosclerosis

GIT Others

Retinopathy, diabetic foot

Alcohol All systems involved, in each case there are different mechanisms of injury. Most common effect of Chronic consumption is alcoholic liver disease resulting in hepatic failure. Actual mechanism for cirrhosis is unknown.

Others include: System Affected

Pathology

Mechanism

Nervous System

Acute depression, Wernicke-Korsakoff ‘s Syndrome,

Toxicity, Thiamine deficiency

CVS

Dilated cardiomyopathy, secondary hypertension Oral cavity, Acute

Direct toxicity, vasopressor effect due to catecholamine release Direct toxicity and

gastritis, pancreatitis, malabsorption

destruction of acini & islets.

Muscle pain and weakness Testicular atrophy

Myoglobin breakdown

GIT

Musculoskeletal Reproductive Sym

and gynaecomastia: Spontaneous abortions: Reduced fertility in both.

Reduction in testosterone and increase in estrogen.

Autopsy Findings • External Examination: – Adult male. – Poor nutritional status. – Hair: sparse and silky. – Ascites. – Bilateral pedal oedema. – Other stigmata of CLD: jaundice, spider nevi,

Internal Examination GIT:  Esophagus: Varices i.e. tortuous dilated vein within the sub mucosa. Mucosa inflamed and hemorrhagic    

Liver:

Gross:

– Marked hepatomegaly, Increased weight (N = 1300g). – Capsule adherent – Cut surface pale . Yellowish brown color. – Usually micronodular, but can also be macronodular or mixed cirrhosis.

• Liver : Histology – Fat vacuoles – Varying degrees of inflammation (Polymorphonuclear cell infiltration) and necrosis – Mallory bodies (alcoholic hyalin) – Diffuse fibrosis. – Regenerating nodules.

Other distinct changes seen in: • Pleural effusion • Vasculature – Atherosclerotic plaques.

• Heart: – Dilated cardiomyopathy – Enlarged heart and dilation of all chambers.

• Brain: – Cerebral oedema

• Lung – Bronchitis – Interstitial lung fibrosis – Increased in weight but no consolidation.

• Kidney • Pyelonephritis

• Spleen • Splenomegally. Increase in size and

Mechanism and Cause of death

Complications of Cirrhosis Cirrhosis Portal Hypertension Esophageal Varices Rapture and bleeding Shock

Death

Questions?