A 75-year-old chronic alcoholic presents to the emergency room after being found on the rail road tracks passed out. On examination, he is found to have a distended abdomen that is equivalent in size to a full term pregnant woman’s belly. Which of the following functions of the liver has been compromised to cause this finding?
A. Lipid metabolism
B. Albumin synthesis
C. Bilirubin metabolism
D. Alcohol detoxification
E. Decreased production of coagulation factors
Answer- The right answer is B- Albumin synthesis.
The patient has alcoholic liver disease. Excessive alcohol intake can lead to fatty liver, hepatitis, and cirrhosis (figure). Alcoholic hepatitis is characterized by acute or chronic inflammation and parenchymal necrosis of the liver induced by alcohol. Cirrhosis is a consequence of chronic liver disease characterized by replacement of liver tissue by fibrous scar tissue as well as regenerative nodules, leading to progressive loss of liver function.
The clinical presentation of alcoholic liver disease can vary from an asymptomatic hepatomegaly to a rapidly fatal acute illness or end-stage cirrhosis. Anemia, hyperlipidemia, hypoglycemia, hyperuricemia, abnormal liver functions and high anion gap acidosis are characteristic of alcoholic liver disease.
Figure- Initially the changes are reversible. Alcohol abstinence can reverse the changes.
In the given situation patient has presented with Ascites, accumulation of fluid in the peritoneum, which is caused by increased back pressure in to the capillaries and decreased concentration of albumin. Albumin is the primary protein that maintains oncotic pressure within the vessels and is synthesized by liver and in such like conditions of liver dysfunction, albumin synthesis is decreased. The concentration of Gamma globulins is increased, A: G ratio is reversed.
Hypoalbuminemia is more common in chronic liver disorders such as cirrhosis and usually reflects severe liver damage and decreased albumin synthesis. Serum albumin has a long half-life: 18–20 days, with ~4% degraded per day Because of this slow turnover, the serum albumin is not a good indicator of acute or mild hepatic dysfunction; only minimal changes in the serum albumin are seen in acute liver conditions . Albumin levels < 3 g/dL should raise the possibility of chronic liver disease. However, hypoalbuminemia is not specific for liver disease and may occur in protein malnutrition of any cause, as well as protein-losing enteropathies, nephrotic syndrome, and chronic infections
All of the functions of liver are affected in alcoholic liver disease. Lipid metabolism is also affected, there is more synthesis of triglycerides and VLDL formation is impaired resulting in fatty liver.
Bilirubin metabolism is also affected, the patients with cirrhosis or end stage liver disease present with hyperbilirubinemia.
Alcohol detoxification is not affected; the body actually becomes more capable of metabolizing alcohol in chronic alcoholics.
The synthesis of coagulation factors is also decreased. Bleeding tendencies are observed in liver failure.With the exception of factor VIII, the blood clotting factors are made exclusively in hepatocytes. Their serum half-lives are much shorter than albumin, ranging from 6 h for factor VII to 5 days for fibrinogen. Because of their rapid turnover, measurement of the clotting factors is the single best acute measure of hepatic synthetic function and helpful in both the diagnosis and assessing the prognosis of acute parenchymal liver disease.
Since in the given case the main emphasis is on Ascites, hence the correct answer is Albumin synthesis.
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