A 45-year-old man with a history of alcohol use disorder, chronic hepatitis C, and HIV is brought to the emergency department due to altered mental status and abdominal distension. He is disoriented and unable to provide an adequate history. He is accompanied by a friend who reports that the patient has recently been drinking heavily. The patient's breath has a sweet, sulfurous odor. Physical examination shows gynecomastia, palmar erythema, and multiple spider angiomata. The abdomen is severely distended, and dilated periumbilical veins are noted. There is 3+ bilateral lower extremity edema. Genital examination shows testicular atrophy. Neurologic examination shows disorientation and asterixis. Abdominal imaging reveals splenomegaly. Development of this patient's gynecomastia most closely resembles the pathogenesis of which of the following additional findings in this patient?

Question

A 45-year-old man with a history of alcohol use disorder, chronic hepatitis C, and HIV is brought to the emergency department due to altered mental status and abdominal distension.  He is disoriented and unable to provide an adequate history.  He is accompanied by a friend who reports that the patient has recently been drinking heavily.  The patient's breath has a sweet, sulfurous odor.  Physical examination shows gynecomastia, palmar erythema, and multiple spider angiomata.  The abdomen is severely distended, and dilated periumbilical veins are noted.  There is 3+ bilateral lower extremity edema.  Genital examination shows testicular atrophy.  Neurologic examination shows disorientation and asterixis.  Abdominal imaging reveals splenomegaly.  Development of this patient's gynecomastia most closely resembles the pathogenesis of which of the following additional findings in this patient?

Quizplus · Accepted Answer

11ec160b_3935_2c9c_9249_9b57cf46a9d9_MD0001_00 This patient has numerous clinical findings characteristic of liver cirrhosis. In patients with cirrhosis, gynecomastia arises from hyperestrinism, which has a number of contributing factors: Cirrhosis increases adrenal production of estrogen precursors (eg, androstenedione), which are subsequently aromatized to estrogens (eg, estrone) Estrogens induce sex hormone-binding globulin production, which results in increased testosterone binding and a further decrease in the free testosterone/estrogen ratio Impaired estrogen metabolism by the liver results in estrogen accumulation Besides gynecomastia, hyperestrinism in patients with cirrhosis can promote the formation of spider angiomata. Spider angiomata are subcutaneous vascular lesions consisting of a central arteriole surrounded by smaller vessels that blanch on compression. They are most frequently found on the trunk, face, and upper limbs. Spider angiomata are likely due to estrogen-induced arteriolar dilation and are also seen in other hyperestrogenic states (eg, pregnancy). The number and size of angiomata generally correlate with the severity of liver disease. (Choices A and F) Altered mental status and a sweet, sulfurous breath odor (fetor hepaticus) are signs of poor hepatic function and accumulation of metabolic toxins (eg, ammonia, dimethyl sulfide). In the healthy liver, ammonia is detoxified to urea, which is then excreted in the urine. In patients with cirrhosis, ammonia accumulates in the blood, resulting in impaired neurotransmission in the CNS and possible brain edema. (Choices B and E) Portal hypertension arises from increased hepatic resistance to portal flow at the sinusoids. This causes increased hydrostatic pressure and dilation of the portosystemic collateral veins in the periumbilical system (caput medusae), lower rectum (anorectal varices), and lower esophagus (esophageal varices). Portal hypertension also leads to ascites and venous congestion of the spleen (splenomegaly). (Choice C) The liver is the primary site of protein synthesis. Liver cirrhosis can result in decreased albumin production, leading to lower intravascular oncotic pressure with fluid extravasation and pitting edema in the lower extremities (pedal edema). Educational objective: In patients with cirrhosis, gynecomastia often occurs due to hyperestrinism, which can also promote the formation of spider angiomata. __________ References: Gynecomastia. (http://www.ncbi.nlm.nih.gov/pubmed/22534349)

A 45-Year-Old Man with a History of Alcohol Use Disorder