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 4.0-11.0 x 109 /L Greatly
Platelets 300x 109/L 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 278 U/L 39-117 U/L Raised
phosphatase
SGOT 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 Hypertension
Cardiovascular Atherosclerosis Effect
Atherosclerosis,
Hypertensive heart
Nervous Sym Neuropathy disease
Cerebrovascular
Renal Nephropathy then accidents
Arteritis,
GIT ESRD
GI dysfunction nephrosclerosis

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, Toxicity, Thiamine
Wernicke-Korsakoff ‘s deficiency
Syndrome,
CVS Dilated Direct toxicity,
cardiomyopathy, vasopressor effect
secondary due to catecholamine
GIT hypertension
Oral cavity, Acute release
Direct toxicity and
gastritis, pancreatitis, destruction of acini &
malabsorption islets.
Musculoskeletal Muscle pain and Myoglobin breakdown
Reproductive Sym weakness
Testicular atrophy Reduction in
and gynaecomastia: testosterone and
Spontaneous increase in estrogen.
abortions:
Reduced fertility in
both.
 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 • Lung
• Vasculature – Bronchitis
– Atherosclerotic – Interstitial lung
plaques. fibrosis
• Heart: – Increased in weight
but no
– Dilated
consolidation.
cardiomyopathy
– Enlarged heart and
• Kidney
dilation of all • Pyelonephritis
chambers. • Spleen
• Brain: • Splenomegally.
– Cerebral oedema Increase in size and
Mechanism and Cause of
death
Complications of Cirrhosis
Cirrhosis

Portal Hypertension

Esophageal Varices

Rapture and bleeding

Shock Death
Questions?