A 50-year-old man with chronic alcoholic cirrhosis develops sudden onset ascites, jaundice, and tender hepatomegaly over 4 weeks. Liver biopsy shows hepatocyte swelling with Mallory-Denk bodies, neutrophilic infiltrates, and pericellular fibrosis in zone 3. Serum AST:ALT ratio is 2:1. What is the diagnosis?

• A Acute viral hepatitis superimposed on cirrhosis
• B Drug-induced liver injury with centrizonal pattern
• C Autoimmune hepatitis flare with plasma cell infiltration
• D Alcoholic hepatitis — characteristic histology with AST:ALT >2 in alcoholic liver disease ✓

Explanation

Alcoholic hepatitis presents with acute deterioration in alcoholic liver disease, characterized histologically by hepatocyte ballooning/swelling, Mallory-Denk bodies (cytoskeletal intermediate filament aggregates), neutrophilic infiltration, and zone 3 pericellular (chicken-wire) fibrosis. The AST:ALT ratio >2 is a useful clinical clue, explained by alcohol-induced mitochondrial damage (elevating AST disproportionately) and pyridoxine deficiency reducing ALT synthesis. Viral hepatitis shows lymphocytic infiltrates and higher ALT.

Reference: Robbins & Cotran Pathologic Basis of Disease, 10th ed.

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