Integrated Case Study: Alcohol Metabolism

Integrated Case Study: Alcohol Metabolism

References in AMA
 
Upon presentation: A 65-year-old female, Ella Jarvis, presents to her physician after an episode of near fainting and persistent nausea.  She is alert and cooperative and she appears fatigued, short-of-breath and unsteady moving from the chair to the exam table.
Her skin is cool, clammy and mild pallor with slight icterus (yellowing of skin). Heart rate is irregular and tachycardic and there is an S3 heart sound present. Jugular venous distension is present at 45 degrees. Bilateral +2-pitting edema is present.
Question:
List several findings that would be concerning in this initial presentation. 
Ella is an attorney who has worked in private practice for 25 years. She estimates she works 70 hours/week between the office and the courtroom. She has attributed her persistent fatigue to her schedule, poor diet (“I usually eat on the run, whatever is available”) and alcohol consumption (“I drink a bottle of wine a couple nights a week, and maybe more at the weekend especially if there are lots of dinners with clients”). Her fatigue has recently worsened and she has been feeling nauseous and light-headed consistently over the last several days.
History: Ella states that she has not experienced any chest pain or pressure, palpitations or weakness of the extremities.  This is the second incident of near-syncope in the past 6 months. She denies depression or anxiety but not feeling well has recently added to her normally high stress level.
Vital Signs: Temp:  98.6
Height: 5′ 7″
BP: 163/97
Weight: 184
Pulse: 140
BMI: 28.8
RR: 20
Pulse Ox (on room air): 92%
A complete metabolic panel is ordered, and the results are below:
 
Parameter
Result
Normal
Glucose
87
70-99 mg/dL
BUN
12
7-22 mg/dL
Creatinine
0.71
0.5-1.2 mg/dL
Na
141
135-145 mmol/L
K
4.9
3.5-5.3 mmol/L
Cl
103
98-109 mmol/L
CO2
24
22-26 mmol/L
Calcium
9.2
8.6-10.2 mg/dL
Phosphorus
2.7
2.6-4.9 mg/dL
Albumin
3.0
3.2-4.6 g/dL
Bilirubin
2.2
0.2-1.2 mg/dL
Lactate dehydrogenase (LDH)
190
99-191 IU/L
Aspartate amino-transferase (AST)
260
12-45 IU/L
Alanine aminotransferase (ALT)
76
<34 IU/L
Alkaline Phosphatase
112
37-107 IU/L
 
Questions:
 

1. How do you interpret levels of glucose, BUN and albumin and what do they tell you about this presentation?
2. How do you interpret the increases in ALT, AST and LDH and what is the most likely cause of this? 

Based on this information and patient history you have concerns of alcohol use disorder and recommend a liver biopsy.  At this time Ella is also referred to cardiology for an EKG and cardiac evaluation.
A liver biopsy is performed and the following pathology is illustrated below.
Pathology report:
Alcohol-related steatosis consistent with small- and large-droplet fat.  Fat accumulation is most prominent near the central vein (asterisk) and extends outward toward the portal tract with increasing severity. In this case, the fat extends into acinus zone 2 or the midzone of the hepatic lobule.
Diagnosis
This diagnosis is discussed with Ella and she wants to schedule a follow up to discuss her alcohol use, life-style modifications and counseling. 
Interactive Case: Assignment Prompt
Describe how alcohol consumption contributes to the pathology presented in the image above. Be sure to address the key terms listed below as part of your discussion; you may address additional etiologies as well. 

Acetoacetate
ß-hydroxybutyrate
Ethanol metabolism
Gluconeogenesis
NADH/NAD+
Fatty acid synthesis
Lipolysis
VLDL
Ketogenesis

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