A 44-year-old man comes to the office due to a 6-month history of fatigue, weakness, and intermittent nausea. The patient has no prior medical problems and takes no medications. He drinks 6-8 cans of beer daily. His blood pressure is 116/74 mm Hg and pulse is 78/min. The patient is alert and oriented. He has significant muscle wasting and nontender enlargement of bilateral parotid glands. Multiple spider angiomas on the upper trunk and extremities are seen. Heart sounds are normal without murmur. Breath sounds are diminished at the right base. The abdomen is mildly distended with shifting dullness. Rectal examination reveals internal hemorrhoids, and stool is guaiac-negative. There is no tremor, and neurologic examination is normal. Laboratory results are as follows:
Abdominal ultrasound reveals splenomegaly, ascites, and an echogenic, shrunken liver without any mass. After his clinical condition is discussed, the patient agrees to strictly follow medical recommendations.
Which of the following studies is most appropriate for this patient?

Question

A 44-year-old man comes to the office due to a 6-month history of fatigue, weakness, and intermittent nausea.  The patient has no prior medical problems and takes no medications.  He drinks 6-8 cans of beer daily.  His blood pressure is 116/74 mm Hg and pulse is 78/min.  The patient is alert and oriented.  He has significant muscle wasting and nontender enlargement of bilateral parotid glands.  Multiple spider angiomas on the upper trunk and extremities are seen.  Heart sounds are normal without murmur.  Breath sounds are diminished at the right base.  The abdomen is mildly distended with shifting dullness.  Rectal examination reveals internal hemorrhoids, and stool is guaiac-negative.  There is no tremor, and neurologic examination is normal.  Laboratory results are as follows:
 Abdominal ultrasound reveals splenomegaly, ascites, and an echogenic, shrunken liver without any mass.  After his clinical condition is discussed, the patient agrees to strictly follow medical recommendations.
Which of the following studies is most appropriate for this patient?

Quizplus · Accepted Answer

11ec25c8_d3e1_ccad_bc81_278d8c4c235b_MD0003_00 This patient with nonspecific symptoms (eg, fatigue, weakness, nausea), shrunken liver, liver function test abnormalities, and evidence of portal hypertension (eg, ascites, hemorrhoids, splenomegaly with thrombocytopenia) most likely has cirrhosis due to chronic alcohol use (eg, macrocytic anemia, aspartate aminotransferase [AST] to alanine aminotransferase [ALT] ratio >2:1, parotid gland enlargement [likely from fatty infiltration due to chronic alcohol use rather than to cirrhosis itself]). Patients with compensated cirrhosis typically either are asymptomatic or have nonspecific symptoms. In contrast, those with decompensated cirrhosis may have jaundice, pruritus, upper gastrointestinal bleeding, abdominal distension due to ascites, or confusion due to hepatic encephalopathy. > If the initial evaluation (history, examination, basic laboratory studies) reveals clinical findings consistent with alcohol liver disease, further evaluation for an underlying cause is not indicated. Instead, management goals should include identifying and treating reversible factors and potential complications (eg, variceal hemorrhage, hepatocellular carcinoma). Esophageal varices are the major cause of morbidity and mortality and can occur in 30%-60% of patients with cirrhosis. As a result, all patients with cirrhosis should undergo screening endoscopy to exclude varices, determine risk of variceal hemorrhage, and indicate strategies for prevention of hemorrhage. (Choice A) This patient's ultrasound revealed no liver masses suggestive of hepatocellular carcinoma. As a result, he does not require CT scan of the abdomen to visualize potential masses. However, all patients with cirrhosis should have a screening ultrasound every 6 months. (Choice B) Alpha-1 antitrypsin (AAT) deficiency should be suspected in patients with evidence of early onset obstructive lung disease or liver disease. However, liver disease in patients with AAT deficiency typically presents at a young age (eg, 10-30), and testing for AAT deficiency is not necessary in those with cirrhosis who have a clear history of and supporting laboratory evidence for heavy alcohol use. (Choice C) Although liver biopsy is the gold standard for confirming cirrhosis, it is not required if the clinical findings (eg, presentation, laboratory findings, radiology studies) strongly suggest both cirrhosis (eg, ascites, portal hypertension) and its cause (eg, alcohol history, AST:ALT ratio), as in this patient. (Choice D) The serum ammonia level is usually checked in patients with cirrhosis and suspected hepatic encephalopathy. In patients without clinical evidence of encephalopathy (eg, confusion, neurologic impairment, sleep disturbances), screening ammonia levels should not be checked routinely as they are neither sensitive nor specific. (Choice E) Hemochromatosis should be suspected in patients with skin hyperpigmentation and liver function abnormalities. Other common manifestations are diabetes and arthralgia. Educational objective: Patients with cirrhosis should undergo screening endoscopy to exclude varices, indicate the risk of variceal hemorrhage, and determine strategies for primary prevention of variceal hemorrhage. References: Endoscopic screening for varices in cirrhotic patients: data from a national endoscopic database. (http://www.ncbi.nlm.nih.gov/pubmed/17185084)

A 44-Year-Old Man Comes to the Office Due to a 6-Month