A 44-year-old man with a history of heavy alcohol consumption comes to the emergency department with a nosebleed after getting into a fight while intoxicated. Continuous local pressure is applied and his bleeding resolves within 30 minutes. A detailed physical examination is performed after the bleeding subsides and shows distended paraumbilical veins, ascites, and a flapping hand tremor on wrist extension. Which of the following laboratory findings would be most indicative of a poor prognosis for this patient?

Question

A 44-year-old man with a history of heavy alcohol consumption comes to the emergency department with a nosebleed after getting into a fight while intoxicated.  Continuous local pressure is applied and his bleeding resolves within 30 minutes.  A detailed physical examination is performed after the bleeding subsides and shows distended paraumbilical veins, ascites, and a flapping hand tremor on wrist extension.  Which of the following laboratory findings would be most indicative of a poor prognosis for this patient?

Quizplus · Accepted Answer

11ec160b_3936_16fe_9249_190a60267a26_MD0001_00 This patient has clinical findings consistent with alcohol-induced cirrhosis, namely signs of portal hypertension (ascites/caput medusa) and hepatic encephalopathy (asterixis). Alcohol-associated hepatic injury evolves through the stages of steatosis (reversible), hepatitis (reversible), and cirrhosis (irreversible). Laboratory findings in cirrhosis reflect both hepatocellular/biliary injury and loss of hepatic function. Hepatocyte injury causes a release of intracellular enzymes and an increase in serum transaminases; biliary injury is reflected by increases in alkaline phosphatase and gamma-glutamyl transpeptidase (GGT). Although these laboratory studies are indicative of ongoing hepatobiliary injury, they do not provide information on the liver's functional reserve, a key determinant of prognosis in patients with cirrhosis. Serum albumin levels and prothrombin time (PT) are better indicators of the liver's biosynthetic function, and its ability to transport and metabolize organic anions is reflected by the serum bilirubin level. Hypoalbuminemia, elevated bilirubin levels, and prolonged PT are signs of inadequate liver function (eg, liver failure) and indicate a poor prognosis in cirrhotic patients. For this reason, they are included in multiple scoring systems used to assess the severity of liver failure and need for transplantation. (Choice A) A high aspartate aminotransferase (AST) indicates hepatocellular injury and release of intracellular enzymes into the blood. AST is classically elevated to more than 2 times the level of alanine aminotransferase in alcohol-associated liver disease. Transaminase elevations do not reflect liver function and do not predict outcomes; these enzymes can be transiently elevated by a number of self-limited processes. (Choice B) Fibrinogen is a coagulation factor and an acute phase protein. Liver fibrinogen synthesis is increased in response to infection or acute inflammation and diminished in liver failure. Therefore, low fibrinogen levels would be expected in liver failure. (Choice C) When the alkaline phosphatase is elevated, serum GGT measurements can differentiate whether the cause is biliary disease or an alternate cause such as bone disease. GGT elevations are more specific for biliary injury. (Choice D) The bleeding time is a measure of platelet function (not liver synthetic function) and is often prolonged in severe alcohol-related liver disease, although with a fair degree of variance. Thrombocytopenia develops with chronic alcohol use due to both direct toxic effects of alcohol on the bone marrow as well as splenic sequestration of platelets. Educational objective: Increased aspartate aminotransferase and alanine aminotransferase are indicators of hepatocellular damage, and increased alkaline phosphatase and gamma-glutamyl transpeptidase indicate biliary injury. Serum albumin levels, bilirubin levels, and prothrombin time are reflective of liver function and are of greatest prognostic significance in patients with cirrhosis.

A 44-Year-Old Man with a History of Heavy Alcohol Consumption