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The
concerns I have for Mr. E is that he may have liver cirrhosis that is alcohol-
related based on the amount of alcohol he ingests on a daily basis. Cirrhosis
of the liver occurs when the liver is slowly deteriorating and is unable to
perform its functions due to a chronic injury that occurs over a long period of
time (months and often even years). Normally, the liver can regenerate cells
when damaged. However, if the injury is long lasting, the cells cannot regenerate.

This leads to the liver creating scar tissue called fibrosis which can lead to
cirrhosis if scar tissue begins to build up and take over most of the liver. If
this happens, healthy liver tissue is replaced with scar tissue and the liver
begins to fail due to the scar tissue inability to perform the job of normal
healthy liver cells.

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Patients with liver cirrhosis often have appearances that are very subtle
such as finger clubbing to the more obvious such as jaundice.1
Mr. E has one of the more noticeable symptoms, jaundice, the yellowish appearance
of his skin. Jaundice occurs when the liver can no longer eliminate bilirubin,
a by product formed when hemoglobin from old red blood cells are broken down.

Normally, the liver metabolize and excrete bilirubin. However, since bilirubin
cannot be metabolized and excreted, it is build up in the blood and often
deposited its yellow pigment into the skin.

To add, Mr.E large abdomen is also due to a non functional liver. One
of the liver’s tasks is to filter blood. However, since the liver is not
functioning, new veins called portosystemic collateral veins are formed.2
Veins in the abdomen serve as a potential collateral channel to the systemic
circulation. These veins are common in portal hypertension due to cirrhosis.2 Portal hypertension develops when there is
a increase in pressure due to blood not being able to flow in the liver
properly leading to a swollen abdomen.2

Furthermore, spider
nevi also appear frequently in alcohol related cirrhosis.3
Rosacea and rhiophyma skin conditions are common as well but are often over
look.3 Mr. E has both spider nevi and
rhiophyma. Additionally, Mr. E shows signs of aging.  In recent studies, aging has been associated
with liver injury.4

1
 O’Shea, Robert S. , Dasarathy,
Srinivasan , McCullough, Arthur J. , “Alcoholic Liver Disease”. Hepatology 51, no. 1 (2010): 307-312.

2
Sharma, Malay., Rameshbabu, Chittapuram S., “Collateral Pathways in Portal
Hypertension”. J Clin Exp Hepatol 2,
no.4 (2012): 338-339.

3
Koulaouzidis, A., Bhat, S., Moschos, J., “Skin manifestations of liver diseases”.

Annals of Hepatology 6, no.3 ( 2007):
181.

4
Kim, Hee , Kisseleva, Tatiana, Brenner, David A., “Aging and liver disease”. Curr Opin Gastroenterol 31, no.3 ( 2015)
184.

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