This patient's presentation is consistent with cirrhosis, for which the most likely cause in this patient is alcohol abuse.
The patient's distended abdomen with shifting dullness is evidence for the presence of ascites, the result of portal hypertension and decreased intravascular oncotic pressure. Spider angiomas (as depicted in Image A) are a type of telangiectasia found frequently in patients with liver disease due to hormonal dysregulation. Gynecomastia, like spider angioma, results from altered sex hormone metabolism.
As reviewed by Starr et al., chronic alcoholism is the leading cause of cirrhosis in the US. Viral hepatitis due to hepatitis B and hepatitis C are also common etiologies. Nonalcoholic fatty liver disease is emerging as an increasingly important cause.
As discussed by Schuppan et al., imaging with ultrasonography, CT and MRI, though useful in very obvious cases, are still not always sensitive enough to detect cirrhosis. The gold standard remains a histologic diagnosis from liver biospy.
Image A shows a spider angioma. Illustration A shows gynecomastia and ascites.
Answer 1: History of a blood transfusion in 1984 puts a patient at risk for HIV and hepatitis C transmission. HIV is not a major cause of cirrhosis. Hepatitis C is the leading cause of cirrhosis, and should be screened, but is less likely a cause in this patient with their history of gout and Wernicke's encephalopathy - two pathologies that are exacerbated by alcohol.
Answer 2: Such a travel history may have exposed the patient to schistosomiasis (among other possible infections), a parasite that resides in the host's liver, but is a rare cause of cirrhosis.
Answer 3: Constant morning headaches and nausea are concerning for increased intracranial pressure. This is not associated with nor a cause of cirrhosis.
Answer 5: Large doses of acetaminophen can result in acute hepatic failure, but are unlikely to cause chronic liver disease leading to cirrhosis.
Starr SP, Raines D. Cirrhosis: diagnosis, management, and prevention. Am Fam Physician. 2011 Dec 15;84(12):1353-9. Review. PubMed PMID: 22230269.
PMID:22230269 (Link to Abstract)
Schuppan D, Afdhal NH. Liver cirrhosis. Lancet. 2008 Mar 8;371(9615):838-51. doi: 10.1016/S0140-6736(08)60383-9. Review. PubMed PMID: 18328931; PubMed Central PMCID: PMC2271178.
PMID:18328931 (Link to Abstract)