ANSWER 7
This man has abnormal liver function tests which indicate hepatic failure; the hypopro-
teinaemia has caused the ascites and ankle swelling. The number of spider naevi is more
than the accepted normal of three. The cause is likely to be alcohol as it is a common
cause of this problem, he is at increased risk through his work in the catering business. His
symptoms of morning nausea and vomiting are typical, and this would account for his
cushingoid appearance (alcohol increases adrenocorticotrophic hormone (ACTH) secre-
tion) and the macrocytsis on the blood film (due to dietary folate deficiency and a direct
toxic action on the bone marrow by alcohol). However his alcohol intake is too low to be
consistent with the diagnosis of alcoholic liver disease. When the provisional diagnosis is
discussed with him though, he eventually admits that his alcohol intake has been at least
40–50 units per week for the last 20 years and has increased further during the last year
after his marriage had ended, the reason for this being his drinking.
The slight reductions in the sodium and urea reflect a chronic reduced intake of salt and
protein; the rise in bilirubin is insufficient to cause jaundice.
Further investigations are the measurement of hepatitis viral serology, which was nega-
tive, and an ultrasound of the abdomen. This showed a slight reduction in liver size, and
an increase in splenic length of 2–3 cm. There was no evidence of a hepatoma. These find-
ings indicate that portal hypertension has developed. A liver biopsy, performed to confirm
the diagnosis, assess the degree of histological damage and exclude other pathology,
showed changes of cirrhosis.
The crucial aim in management is to impress upon the patient the necessity to stop drink-
ing alcohol, in view of the degree of liver damage, the presumed portal hypertension and
the risk of oesophageal varices and bleeding, and to effect this by his attending an alco-
hol addiction unit. In the short term he should also improve his diet to increase his pro-
tein intake. Diuretics could be used to reduce his oedema, but it should be remembered
that they could cause postural hypotension more easily against this background.
His attendance at the addiction unit was fitful, he continued to drink heavily and he died
3 years later as a result of a second bleed from oesophageal varices.
- Patients who drink excessive amounts of alcohol will often disguise this fact in their
history - Alcoholic liver disease has a poor prognosis if the alcohol intake is not terminated.