A 68-year-old woman comes to the emergency department due to shortness of breath, poor appetite, and abdominal distension for the past 3 months. Her symptoms have progressively worsened, and now she is unable to perform her daily activities. The patient has a history of coronary artery disease and underwent coronary artery bypass grafting 3 years ago. She also has myelodysplastic syndrome for which she receives intermittent blood transfusions. Physical examination shows jugular venous distension, abdominal distension, hepatomegaly, and lower extremity edema. A representative liver biopsy image is shown in the exhibit.
Which of the following is the most likely cause of this patient's liver findings?

Question

A 68-year-old woman comes to the emergency department due to shortness of breath, poor appetite, and abdominal distension for the past 3 months.  Her symptoms have progressively worsened, and now she is unable to perform her daily activities.  The patient has a history of coronary artery disease and underwent coronary artery bypass grafting 3 years ago.  She also has myelodysplastic syndrome for which she receives intermittent blood transfusions.  Physical examination shows jugular venous distension, abdominal distension, hepatomegaly, and lower extremity edema.  A representative liver biopsy image is shown in the exhibit. 
 Which of the following is the most likely cause of this patient's liver findings?

Quizplus · Accepted Answer

11ec160b_3929_6cba_9249_3d6f7fc2a024_MD0001_00 This patient's shortness of breath-accompanied by abdominal distension (ascites), hepatomegaly, jugular venous distension, and lower extremity edema-is consistent with right-sided heart failure; her liver biopsy demonstrates evidence of congestive hepatopathy. In congestive hepatopathy, outflow of blood from the hepatic veins is impeded by elevated right atrial and vena caval pressures, which leads to increased hydrostatic pressure in the central veins of the liver. There is consequent seepage of fluid into the surrounding hepatocytes with resulting congestion and hepatic necrosis. The hepatocellular damage favors the centrilobular areas (zone 3) where congestion is most prominent. On microscopy, patchy hemorrhage is seen surrounding the central veins consistent with centrilobular necrosis. These areas of necrosis contrast with the relatively normal-appearing hepatocytes in the periportal regions (zone 1), creating an overall heterogenous appearance sometimes referred to as "nutmeg liver." In addition to signs and symptoms of right-sided heart failure, patients with congestive hepatopathy may have localized right upper quadrant pain (due to stretching of the hepatic capsule), and laboratory results may demonstrate modest elevations in serum bilirubin and transaminases. (Choice A) Autoimmune destruction of intrahepatic biliary ducts occurs in primary biliary cholangitis (formerly primary biliary cirrhosis). Because intrahepatic bile ducts are concentrated in the periportal regions, histopathology demonstrates periductal fibrosis predominantly in those regions. (Choice B) Excessive hepatic deposition of iron most commonly occurs due to hemochromatosis. Patients receiving frequent blood transfusions are also at risk; however, histopathology would demonstrate periportal fibrosis and numerous brown pigments representing iron deposits. Fibrosis favors the periportal regions likely because those hepatocytes are exposed to the highest concentrations of iron-rich blood coming from the portal vein. (Choice C) Histopathology in chronic viral hepatitis (eg, chronic hepatitis C) reveals dense infiltrate of mononuclear inflammatory cells in the periportal regions; there is often gradual development of periportal fibrosis that may eventually bridge to the centrilobular regions. (Choice D) Histopathology of metastatic spread to the liver is unlikely to demonstrate a consistent pattern of lobular necrosis, but it can reveal an abrupt demarcation between normal hepatocellular tissue and the metastatic tumor. Educational objective: Congestive hepatopathy is a common complication of right-sided heart failure. Patchy hemorrhage and necrosis predominantly affect the centrilobular regions (zone 3) where hepatic congestion is most prominent. The centrilobular necrosis, combined with relatively normal-appearing periportal regions (zone 1), creates an overall heterogenous appearance sometimes referred to as "nutmeg liver."

A 68-Year-Old Woman Comes to the Emergency Department Due to Shortness