A 54-year-old man comes to the office due to 6 months of fatigue, anorexia, and a 7-kg (15.4-lb) unintentional weight loss. The patient has noticed that despite his weight loss, his pants are getting tighter and his socks leave deep imprints on his legs. He has a history of hypertension for which he takes amlodipine. He is unaware of any family history as he was adopted. The patient has smoked 5-6 cigarettes daily for the past 30 years and drinks 1 or 2 cans of beer on weekends. He has a remote history of injection drug use. Blood pressure is 134/82 mm Hg, pulse is 84/min, and BMI is 23 kg/m². Jugular venous pressure is normal. The patient has bilateral gynecomastia and several spider angiomas on his upper trunk. Cardiac examination reveals normal heart sounds without any murmurs. Breath sounds are decreased at the bases. The abdomen is soft, nontender, and distended with shifting dullness. There is bilateral lower extremity pitting edema. Which of the following is the most likely underlying cause of this patient's condition?

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11ec25c8_d3e1_306a_bc81_8bd83293329f_MD0003_00 This patient with pedal edema, ascites (shifting dullness), bilateral gynecomastia, and spider angiomata likely has cirrhosis and portal hypertension. Other clinical features that suggest cirrhosis include palmar erythema, caput medusa, and splenomegaly. The most common causes of cirrhosis in the United States include viral hepatitis (C more than B), chronic alcoholism, nonalcoholic fatty liver disease (NAFLD), and hemochromatosis. The initial evaluation of patients with suspected cirrhosis consists of obtaining a medical history, including inquiring about medications, social habits (eg, alcohol use, drug use, high-risk sexual activity), and family history (eg, to exclude hemochromatosis). Given this patient's history of intravenous drug use, the most likely cause of his cirrhosis is an infection with viral hepatitis (which, along with alcohol use, accounts for ~50% of cases of cirrhosis). He has no significant alcohol history. He is not overweight and is therefore unlikely to have NAFLD. His family history is unknown, but he has no stigmata of hemochromatosis (eg, bronze diabetes, cardiomyopathy, arthropathy). Laboratory studies, including viral hepatitis serologies and iron studies, should be obtained. If these are unrevealing, the patient may require further investigation for the less common causes of cirrhosis. (Choice A) Amlodipine can cause pedal edema, but not cirrhosis. Medications (eg, methotrexate, isoniazid) can cause cirrhosis, but this is less common. (Choice C) Cor pulmonale can cause fatigue and leg edema but not gynecomastia or spider angiomata; it would be unlikely in the absence of other manifestations (eg, exertional dyspnea, syncope, angina, loud second heart sound, prominent a wave). (Choice D) Hypothyroidism can cause fatigue, pleural and pericardial effusions, ascites, and pedal edema; however, these findings are rare in the absence of severe hypothyroidism (eg, cold intolerance, constipation, weight gain, bradycardia, goiter). Hypothyroidism would be unlikely to cause gynecomastia or spider angiomata. (Choice E) Lung cancer could lead to fatigue, weight loss, anorexia, edema of the legs, and ascites in patients with advanced disease (eg, metastatic compression of the lymphatics, peritoneal carcinomatosis), but it would not likely cause gynecomastia or spider angiomata. (Choice F) Nephrotic syndrome can cause anasarca but is not usually associated with spider angiomata or gynecomastia. Educational objective: Cirrhosis should be suspected in any patient with evidence of chronic liver disease (eg, ascites, spider angiomata, gynecomastia, splenomegaly). Viral hepatitis, chronic alcohol abuse, nonalcoholic fatty liver disease, and hemochromatosis are the most common causes of cirrhosis in the United States. References: Cirrhosis and chronic liver failure: part I. Diagnosis and evaluation. (http://www.ncbi.nlm.nih.gov/pubmed/16970019) Treatment of patients with cirrhosis. (http://www.ncbi.nlm.nih.gov/pubmed/27557303)

A 54-Year-Old Man Comes to the Office Due to 6