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Vol. 30, pp.455 462, 2002 1 14 8 1 28 18 8 11 AST γ-gtp CT 29 1550 g 1~6 1 2 ARDS 28 ; 5 1 10 1 t; 40 10 8 6 3 233

Table 1 Laboratory data on first admission Blood Cell Count WBC 23,800 /µl RBC 312 10 4 /µl Hb 11.5 g/dl Hct 32.3 % PLT 14.2 10 4 /µl Coagulation PT 40.1 % HPT 60.6 % Biochemistry TP 5.7 g/dl Alb 2.8 g/dl T-Bil 33.5 mg/dl D-Bil 24.2 mg/dl AST 165 IU/l ALT 53 IU/l LDH 356 IU/l ALP 425 IU/l γ-gtp 192 IU/l LAP 78 IU/l ChE 2.5 IU/l BUN 30.1 mg/dl Cr 2.1 mg/dl Na 139 meq/l K 4.4 meq/l Cl 104 meq/l Chol 128 mg/dl CRP 7.5 mg/dl NH3 47 µg/dl FPG 220 mg/dl Serology IgG 1,890 mg/dl IgM 290 mg/dl IgA 440 mg/dl Viral Markers HBs-Ag ( ) anti-hbs ( ) anti-hcv ( ) T. Bil 27.0 mg/dlast 304 IU/lALT 104 IU/lALP 332 IU/l 9 9 22 T. Bil 1.2 mg/dlast 170 IU/lALT 109 IU/lALP 464 IU/l γ-gtp 118 IU/l 11 7 20 8 7 Table 1 CT GI Table 2 Laboratory data on second admission Blood Cell Count WBC 7,300 /µl RBC 229 10 4 /µl Hb 8.4 g/dl Hct 24.1 % PLT 13.0 10 4 /µl Coagulation PT 36.0 % HPT 32.0 % Biochemistry TP 4.0 g/dl Alb 3.0 g/dl T-Bil 27.1 mg/dl D-Bil 21.0 mg/dl AST 67 IU/l ALT 38 IU/l LDH 354 IU/l ALP 304 IU/l γ-gtp 81 IU/l LAP 88 IU/l ChE 2.5 IU/l BUN 19.0 mg/dl Cr 1.2 mg/dl Na 135 meq/l K 3.3 meq/l Cl 96 meq/l Chol 82 mg/dl CRP 6.0 mg/dl NH3 26 µg/dl FPG 103 mg/dl Serology IgG 689 mg/dl IgM 71 mg/dl IgA 110 mg/dl Viral Markers HBs-Ag ( ) anti-hbs ( ) anti-hcv ( ) Pleural effusion SG 1.010 Fibrin ( ) ph 8.0 Rivalta ( ) cell count 176 (Mono. 152, Seg. 24) Occult blood(3+) 168 cm 62 kg 37.4 C 152/80 mmhg 100, ;, 96 cm 4 Table 1 CRP 14.2 µl HBs HBc HCV II 234

Fig. 1 a b c d a; Chest X-ray on admission. b; Chest X-ray reveals infiltration of bilateral lung field. c, d; Chest X-ray and CT scan shows exacerbation of congestive shadow. Fig. 2 Abdominal CT scan shows hepatosplenomegaly with massive ascites. Table 2CRP X Fig. 1-a CTFig. 2 Fig. 3 CRP GI H1 stage 9 2 X Fig. 1-b Fig. 1-c ph 7.404PaO2 49.9 mmhgpaco2 31.4 mmhg CT air bronchogram Fig. 1-d ARDS 9 21 235

a b Fig. 3 Clinical course after admission. 1550 g 490 g Fig. 4- a, b 790 g 880 g 4-c 300 ml 200 ml 400 ml acute on chronic Fig. 5a, b, c ARDS Fig. 5-d 1 c Fig. 4 Gross appearance of the liver and lung at autopsy. a; Liver weight was 1550 g and multiple small nodules with thin septa were seen on the surface. b; Constiguity. c; Both lungs were voluminous, edematous and focally congestive. The weight of both lungs were 790 g and 880 g, respectively. 1 3 236

a b c d Fig. 5 Microscopical findings. a; Mono-sublobular pseudolobular formation with narrow septa. b; Marked bilestasis in the periportal area. Fibrous septa was generally narrow with mild mononuclear cell proliferation. c; Parenchymal damages with Mallory body (arrow). d; Scattered foci of hyline membrane in the lung. Note alveolar destruction with congestion and inflammation. Dotted tumorlet and membranes are seen. 7 ARDS ARDS X ARDS 89 1 Theodossi 8 27% 77% Chedid 9 4 58% 35% CRP 237

Table 3 Reported cases of severe alcoholic hepatitis Pt. No. Age Sex Outcome GI PI ATIII CS PE HD Other therapy 1 56 M Dead + Splenic arterial infusion therapy 2 55 F Dead + 3 67 M Dead + 4 50 M Dead + + + Continuous hemofiltration 5 43 M Dead + + 6 31 F Dead + + + PGE1 7 66 M Dead + + Splenic arterial infusion therapy 8 36 M Dead + + + + Splenic arterial infusion therapy, PGE1 9 54 M Dead + + + + PGE1 10 35 F Dead + + + Splenic arterial infusion therapy 11 55 F Dead + + PGE1 12 28 M Dead + + 13 33 M Alive + + + + 14 24 F Alive + + + + 15 44 M Alive + + 16 43 M Alive + + + 17 45 F Alive + + + PGE1 18 61 M Alive PGE1 19 31 M Alive + + + PGE1 20 49 F Alive + + + + + HBO 21 67 M Alive + 22 60 M Alive + + + 23 61 M Alive + + 24 40 M Alive + + + 25 44 F Alive + + 26 47 M Alive + + GI: Glucagon-Insulin Therapy. PI: Protease Inhibitor. ATIII: Anti-Thrombin III. CS: Corticosteroid. PE: Plasma Exchange. HD: Hemodialysis. PGE1: Plostaglandin E1. HBO: Hyperbaric Oxygen. 10 1 t 28 Table 3 15 translocation TNF-α IL-2 SIRS 15, 17 10~14 1 PE: 238

HD:,,, PMX: PE CHDF 2 13, 14 PMX 2 1 21 1,,,,,,,,,,,,. ( 3) 1992. 1994; 91: 887-898. 2,.., 7,,, 1988: 405-415. 3,,,,,,,,,,,,.. 1993; 34: 888-896. 4,,,. ARDS. 1996; 20: 667-676. 5 Furube M, Sugimoto M, Asakura I, Mizukami H, Akita H, Hatori T, Abei T and Sasaki K. Sex difference in alcoholic liver disease: with special reference to the severity of alcoholic hepatitis. Arukoru Kenkyuto Yakubutsu Ison 1989; 24: 135-143. 6 Tesh VL, Vukajlovish SW and Morrison DC. Pathophysiological effects, clinical significance, and phamacological control. New York, Aran R Liss, 1988: 47-62. 7,,,.. 1997; 35: 319-324. 8 Theodossi A, et al. Controlled trial of methylpredonisolone therapy in severe acute alcoholic hepatitis. Gut 1982; 23: 75-79. 9 Chedid A, et al. Prognostic factors in alcoholic liver disease. Am J Gastroenterol 1991; 86: 211-217. 10,,,.,. 1997; 8: 3-6. 11 Nolan JP. The role of endotoxin in liver injury. Gastroenterology 1975; 69: 1346-1356. 12 Nolan JP. Endotoxin, reticulo-endothelial function, and liver injury. Hepatology 1981; 1: 458-465. 13 Nolan JP. Intestinal endotoxins as mediators of hepatic injury. Hepatology 1989; 10: 887-891. 14 Bode C, Kugler V and Bode JC. Endoxemia in patients with alcoholic and non-alcoholic cirrhosis and in subjects with no evidence of chronic liver disease following acute alcohol excess. J Hepatol 1987; 4: 8-14. 15,,,.. 2000; 40: 69-79. 239

Abstract A Young Male Case with Alcoholic Cirrhosis Complicated, by Severe Alcoholic Hepatitis and was Dead of Multiple Organ Failure Nahoko Okamoto 1, Hiroshi Yotsuyanagi 1, Yoshihiko Nagase 1, Kazuhiko Fujita 1, Takeshi Hayashi 1, Michihiro Suzuki 1, Takehiko Kobayashi 2, Shirou Maeyama 2, Toshiyuki Uchikoshi 2, and Shirou Iino 1 The presented case is a 28-year-old man with a history of alcohol overtake since the age of 18 years. Even after admission for alcoholic hepatitis three years ago, he continued alcohol overtake. He was admitted to our hospital in 1999 complaining of fever, jaundice, and ascites. Laboratory data on admission showed leukocytosis and high levels of transaminases, bilirubin, and γ-gtp. Thrombocytopenia, hyperanmoniemia, and low levels of serum protein were also noted. Abdominal computed tomography revealed irregular-surfaced liver with splenomegaly accompanied by massive ascites. From these findings, we diagnosed him as severe alcoholic hepatitis with liver cirrhosis. In spite of intensive therapy, he suffered from pneumonia, which lead to adult-respiratory-distress syndrome. He died multiple organ failure on the 29th day, after admission. Autopsy disclosed type F liver cirrhosis and congestive lung. Histological examination of the liver showed multiple Mallory-bodies and polymorphic neutrophils in addition to micronodular cirrhosis. He is the youngest Japanese male among reported cases of severe alcoholic hepatitis. (St. Marianna Med. J., 30: 455 462, 2002) 1 Division of Gastroenterology and Hepatology, Department of Internal Medicine 2 Department of Pathology St. Marianna University School of Medicine, 2-16-1 Sugao, Miyamae-ku, Kawasaki 216-8511, Japan 240