A 65-year-old man is brought to the emergency room in a disoriented state. The patient has an odor of alcohol on his breath. Physical examination reveals palmar erythema, diffuse spider angiomata on the upper trunk and face, and gynecomastia. A liver biopsy shows micronodular cirrhosis, massive steatosis, and Mallory hyaline. Serum levels of ammonia are elevated. Which of the following is the most likely underlying cause of gynecomastia in this patient?

This patient is in hepatic coma and likely suffers from cirrhosis. Chronic liver failure in men leads to feminization, characterized by gynecomastia, female body habitus, and a change in pubic hair distribution. Other features of chronic liver disease include spider angiomata and palmar erythema. These findings are attributed to reduced hepatic catabolism of estrogens (i.e., hyperestrogenism). The other choices are unrelated to feminization.Diagnosis: Alcoholic liver disease