A 41-year-old man comes to the office due to progressive abdominal distension for the past 3 months. He reports that his abdomen feels heavy and although uncomfortable, the feeling has not been severe enough to interfere with activities of daily living. The patient drinks 8-10 beers a day and was previously hospitalized for alcohol-induced hepatitis. Vital signs are within normal limits. There is no jaundice. Heart and lung sounds are unremarkable. The liver edge is nodular and palpable 4 cm below the right costal margin. A right upper quadrant ultrasound demonstrates cirrhosis and the presence of intraperitoneal fluid. Which of the following would most likely lead to a decrease in both liver inflammation and portal pressure?

Question

A 41-year-old man comes to the office due to progressive abdominal distension for the past 3 months.  He reports that his abdomen feels heavy and although uncomfortable, the feeling has not been severe enough to interfere with activities of daily living.  The patient drinks 8-10 beers a day and was previously hospitalized for alcohol-induced hepatitis.  Vital signs are within normal limits.  There is no jaundice.  Heart and lung sounds are unremarkable.  The liver edge is nodular and palpable 4 cm below the right costal margin.  A right upper quadrant ultrasound demonstrates cirrhosis and the presence of intraperitoneal fluid.  Which of the following would most likely lead to a decrease in both liver inflammation and portal pressure?

Quizplus · Accepted Answer

This patient with hepatic cirrhosis has developed ascites (ie, peritoneal fluid on ultrasound). Given his heavy alcohol intake and history of alcoholic hepatitis, this presentation suggests decompensated alcoholic cirrhosis. Cirrhosis develops in the setting of chronic liver disease (eg, alcohol use, as in this patient), which leads to progressive hepatic fibrosis and regenerative nodule formation. Although advanced cirrhosis is irreversible, many patients have concurrent alcohol-related liver inflammation and active fibrogenesis that improves with abstinence from alcohol. In addition, abstinence leads to a reduction in portal pressure, which can make ascites more diuretic-responsive and ultimately aids in its resolution. Alcohol cessation also carries a significant survival benefit compared with patients who continue to drink and should be recommended in all patients with cirrhosis. Baclofen has been shown to decrease alcohol cravings in patients with alcoholic liver disease and can help with cessation. (Choice A) In patients with cirrhosis, the renin-angiotensin-aldosterone system counteracts the effects of splanchnic vasodilation to prevent systemic hypotension. Because ACE inhibitors blunt this important compensatory response, they should be avoided in all patients with cirrhosis. (Choice B) Nonselective beta blockers are used to prevent bleeding in patients with known esophageal varices; however, they can be harmful in patients with ascites due to progressive hypotension. In this patient with ascites and no known esophageal varices, nonselective beta blockers should be avoided. (Choice D) Diuretics (eg, spironolactone, furosemide) can improve ascites by inducing natriuresis and are considered first-line therapy in addition to alcohol abstinence and a low-sodium diet. However, they would not be expected to reverse liver inflammation. (Choice E) Ursodeoxycholic acid prevents the accumulation of toxic bile acids in the liver and can effectively reverse liver inflammation in patients with primary biliary cholangitis. However, it has no role in the management of alcoholic cirrhosis. Educational objective: In patients with alcoholic cirrhosis, cessation of alcohol use can reduce liver inflammation, fibrogenesis, and portal pressure, which can lead to the resolution of ascites and, ultimately, improved survival. Alcohol abstinence should be recommended in all patients with cirrhosis. References: Introduction to the revised American Association for the Study of Liver Diseases practice guideline management of adult patients with ascites due to cirrhosis 2012. (http://www.ncbi.nlm.nih.gov/pubmed/23463403) Indication of liver transplantation in severe alcoholic liver cirrhosis: quantitative evaluation and optimal timing. (http://www.ncbi.nlm.nih.gov/pubmed/11804670)

A 41-Year-Old Man Comes to the Office Due to Progressive