Question: A 51 year old male presents to the hospital with new onset of jaundice and there is a concern for decompensated cirrhosis due to alcohol. The patient insists that he does not drink more than 1-2 glasses of wine per day. You decide to perform liver biopsy to get to the bottom of things. Which of the following would argue against EtOH as the etiology of his liver disease?
A. a granuloma
B. hyaline inside hepatocytes
C. steatosis (< 10% of tissue)
D. neutraphilic infiltrate
Answer: Sometimes we have to rely on the liver biopsy to explain the etiology of somebody’s disease. In the case of alcoholic liver disease, there are several suggestive findings on liver biopsy. Among them is hyaline, termed Mallory’s hyaline, and exists as a pink, ropy aggregate in the cytoplasm of hepatocytes.
In addition, steatosis is common. Don’t be fooled by the percentage of steatosis in cirrhosis (it can be low as an overall percentage as the degree of fibrosis builds). A neutraphilic infiltrate suggests active EtOH use; it is present in alcoholic hepatitis (which may account for this patient’s jaundice as well). Neutraphils are often the first histologic component to regress after sobriety is achieved.
The granuloma, if present, does not sway you one way or another with respect to alcohol use. It is more common in PBC, drugs, infections (TB, fungal), lymphoma, sarcoidosis…and may even be seen in normal patients.